Basic Information
Provider Information | |||||||||
NPI: | 1871896498 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FOX | ||||||||
FirstName: | BRITTANY | ||||||||
MiddleName: | RAE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LEE | ||||||||
OtherFirstName: | BRITTANY | ||||||||
OtherMiddleName: | RAE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DPT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 600 CENTRAL AVE STE C | ||||||||
Address2: |   | ||||||||
City: | LAKE ELSINORE | ||||||||
State: | CA | ||||||||
PostalCode: | 925302749 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9516969353 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 25150 HANCOCK AVE | ||||||||
Address2: | SUITE 100 | ||||||||
City: | MURRIETA | ||||||||
State: | CA | ||||||||
PostalCode: | 925625987 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9516987720 | ||||||||
FaxNumber: | 9516987451 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/21/2010 | ||||||||
LastUpdateDate: | 01/05/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/02/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT 37392 | CA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 0273974 | 01 |   | WASHINGTON STATE DEPT OF LABOR AND INDUSTRIES | OTHER |