Basic Information
Provider Information | |||||||||
NPI: | 1316210933 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARTIN | ||||||||
FirstName: | AMANDA | ||||||||
MiddleName: | MARYELLEN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DEKOKER | ||||||||
OtherFirstName: | AMANDA | ||||||||
OtherMiddleName: | MARYELLEN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 24630 WASHINGTON AVE | ||||||||
Address2: | SUITE 200 | ||||||||
City: | MURRIETA | ||||||||
State: | CA | ||||||||
PostalCode: | 925626177 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9516969353 | ||||||||
FaxNumber: | 9519737216 | ||||||||
Practice Location | |||||||||
Address1: | 521 E ELDER ST | ||||||||
Address2: | SUITE 106 | ||||||||
City: | FALLBROOK | ||||||||
State: | CA | ||||||||
PostalCode: | 920283081 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7607238337 | ||||||||
FaxNumber: | 7607235476 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/13/2012 | ||||||||
LastUpdateDate: | 03/31/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT 38573 | CA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 0PT385730 | 01 | CA | BLUE SHIELD PIN | OTHER | 12369967 | 01 | CA | CAQH PROVIDER ID | OTHER |