Basic Information
| Provider Information | |||||||||
| NPI: | 1316981269 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANTHRUM | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MPT, OCS, CSCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2403 KELLOGG CT | ||||||||
| Address2: | |||||||||
| City: | DUARTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910102155 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 671 W NAOMI AVE | ||||||||
| Address2: | |||||||||
| City: | ARCADIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910077502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264467027 | ||||||||
| FaxNumber: | 6264464723 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT25650 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.