Healthcare Provider Details

I. General information

NPI: 1740999739
Provider Name (Legal Business Name): RICARDO HERNANDEZ JR. PT DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2022
Last Update Date: 11/17/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32261 CAMINO CAPISTRANO STE D101
SAN JUAN CAPISTRANO CA
92675-3747
US

IV. Provider business mailing address

24 REGALO DR
MISSION VIEJO CA
92692-5100
US

V. Phone/Fax

Practice location:
  • Phone: 949-429-2155
  • Fax:
Mailing address:
  • Phone: 760-899-8704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number303164
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: