Healthcare Provider Details

I. General information

NPI: 1760519177
Provider Name (Legal Business Name): BRISTOL PHYSICAL THERAPY & SPORTS MEDICINE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2703 N BRISTOL STREET SUITE H 1
SANTA ANA CA
92706-1472
US

IV. Provider business mailing address

2703 N BRISTOL STREET SUITE H 1
SANTA ANA CA
92706-1472
US

V. Phone/Fax

Practice location:
  • Phone: 714-664-0411
  • Fax: 714-664-0402
Mailing address:
  • Phone: 714-664-0411
  • Fax: 714-664-0402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number188825
License Number StateCA

VIII. Authorized Official

Name: MRS. TERESA VAZQUEZ
Title or Position: CHIEF EXECUTIVE
Credential:
Phone: 714-648-0335