Healthcare Provider Details

I. General information

NPI: 1285910679
Provider Name (Legal Business Name): MARC ALLEN BROBERG PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2011
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3418 LOMA VISTA RD SUITE A
VENTURA CA
93003-3016
US

IV. Provider business mailing address

3418 LOMA VISTA RD SUITE A
VENTURA CA
93003-3016
US

V. Phone/Fax

Practice location:
  • Phone: 805-410-1363
  • Fax:
Mailing address:
  • Phone: 805-223-0508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number27877
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: