=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831789296
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MORTEN GRAVERSEN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2021
-----------------------------------------------------
Last Update Date | 10/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1850 N RIVERSIDE AVE STE 240
-----------------------------------------------------
City | RIALTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92376-8082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-258-2220
-----------------------------------------------------
Fax | 909-258-2102
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 671 AVENIDA CARMEL
-----------------------------------------------------
City | COLTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92324-1367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-364-1277
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT299762
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------