Healthcare Provider Details

I. General information

NPI: 1104721257
Provider Name (Legal Business Name): ETHAN OSBORNE PHYSICAL THERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17871 SANTIAGO BLVD STE 205
VILLA PARK CA
92861-4119
US

IV. Provider business mailing address

6601 VISTA LOMA
YORBA LINDA CA
92886-6454
US

V. Phone/Fax

Practice location:
  • Phone: 714-464-7698
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: ETHAN GREGORY OSBORNE
Title or Position: OWNER
Credential: DPT
Phone: 949-278-1640