Healthcare Provider Details

I. General information

NPI: 1447206651
Provider Name (Legal Business Name): JULIE TERI EZAKI PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W SANTA ANA BLVD #100
SANTA ANA CA
92701-4134
US

IV. Provider business mailing address

24171 PAVION
MISSION VIEJO CA
92692-2200
US

V. Phone/Fax

Practice location:
  • Phone: 714-347-0300
  • Fax:
Mailing address:
  • Phone: 949-707-2190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberAT 5059
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: