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General NPI Number Information
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NPI Number | 1033500178
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Entity Type | Individual
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Provider Name | TODD VAN ETTEN
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Gender | Male
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Dates
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Enumeration Date | 02/11/2015
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Last Update Date | 02/11/2015
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Provider Practice Location Address
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Address Line | 26318 MISTY GLN
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City | LAKE FOREST
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State | CA
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Zip | 92630-7249
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Country | US
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Telephone | 949-202-8905
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Fax |
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Provider Business Mailing Address
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Address Line | 26318 MISTY GLN
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City | LAKE FOREST
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State | CA
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Zip | 92630-7249
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Country | US
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Telephone | 949-202-8905
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 9605
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License Number State | CA
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