Healthcare Provider Details

I. General information

NPI: 1265417109
Provider Name (Legal Business Name): MARK WINSTON NOLTE PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 10/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 E 4TH ST STE 170
SANTA ANA CA
92705-3814
US

IV. Provider business mailing address

200 NEWPORT CENTER DR STE 213
NEWPORT BEACH CA
92660-7501
US

V. Phone/Fax

Practice location:
  • Phone: 714-558-3977
  • Fax: 714-558-0308
Mailing address:
  • Phone: 949-644-1322
  • Fax: 949-644-0316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT20582
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: