Basic Information
| Provider Information | |||||||||
| NPI: | 1982041208 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROUHARD | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | PAUL | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8510 BALBOA BLVD | ||||||||
| Address2: | STE 150 | ||||||||
| City: | NORTHRIDGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913253583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8186543400 | ||||||||
| FaxNumber: | 8186543417 | ||||||||
| Practice Location | |||||||||
| Address1: | 343 S MOORPARK RD | ||||||||
| Address2: | |||||||||
| City: | THOUSAND OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913611008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054130160 | ||||||||
| FaxNumber: | 8054130161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2013 | ||||||||
| LastUpdateDate: | 05/28/2013 | ||||||||
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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 | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.