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General NPI Number Information
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NPI Number | 1942435045
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Entity Type | Organization
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Legal Business Name | BLUE WATER PHYSICAL THERAPY
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Dates
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Enumeration Date | 05/19/2009
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Last Update Date | 01/28/2015
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Provider Practice Location Address
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Address Line | 2063 SAN ELIJO AVE
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City | CARDIFF
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State | CA
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Zip | 92007-1726
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Country | US
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Telephone | 714-623-2035
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Fax |
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Provider Business Mailing Address
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Address Line | 2063 SAN ELIJO AVE
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City | CARDIFF
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State | CA
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Zip | 92007-1726
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Country | US
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Telephone | 714-623-2035
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. ERIN RENEE MALECHA
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Credential | MPT
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Telephone | 714-623-2035
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT30454
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License Number State | CA
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