Basic Information
| Provider Information | |||||||||
| NPI: | 1083963839 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSTAD | ||||||||
| FirstName: | LAURETTA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24630 WASHINGTON AVE | ||||||||
| Address2: | STE. 200 | ||||||||
| City: | MURRIETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925626131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516969353 | ||||||||
| FaxNumber: | 9519737216 | ||||||||
| Practice Location | |||||||||
| Address1: | 12402 INDUSTRIAL BLVD | ||||||||
| Address2: | SUITE B-2 | ||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923955871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609556061 | ||||||||
| FaxNumber: | 7609556062 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2012 | ||||||||
| LastUpdateDate: | 03/02/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 39367 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.