Basic Information
| Provider Information | |||||||||
| NPI: | 1619641859 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOULL | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 CREEKSIDE DR UNIT 320 | ||||||||
| Address2: | |||||||||
| City: | SAN MARCOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920782363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607125459 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10800 MAGNOLIA AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925053043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513532000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2021 | ||||||||
| LastUpdateDate: | 08/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 300503 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.