Healthcare Provider Details

I. General information

NPI: 1043295124
Provider Name (Legal Business Name): KEVIN ROBERT BRESNAHAN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2005
Last Update Date: 04/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10225 AUSTIN DRIVE # 204
SPRING VALLEY CA
91978
US

IV. Provider business mailing address

317 N EL CAMINO REAL #210
ENCINITAS CA
92024-2811
US

V. Phone/Fax

Practice location:
  • Phone: 619-670-4567
  • Fax: 619-670-0200
Mailing address:
  • Phone: 760-634-0248
  • Fax: 760-634-1782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 14228
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: