Basic Information
| Provider Information | |||||||||
| NPI: | 1164738076 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YARDIMIAN | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | BULLARD | ||||||||
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| Credential: | DPT | ||||||||
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| OtherLastName: | BULLARD | ||||||||
| OtherFirstName: | CAROLYN | ||||||||
| OtherMiddleName: | CORINNE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 24630 WASHINGTON AVE | ||||||||
| Address2: | STE. 200 | ||||||||
| City: | MURRIETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925626177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516969353 | ||||||||
| FaxNumber: | 9519737216 | ||||||||
| Practice Location | |||||||||
| Address1: | 886 MAGNOLIA AVE | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | CORONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928793105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513403402 | ||||||||
| FaxNumber: | 9513403416 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2010 | ||||||||
| LastUpdateDate: | 12/10/2013 | ||||||||
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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 | PT37123 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0PT371230 | 01 | CA | BLUE SHIELD OF CALIFORNIA | OTHER |