1255007050 NPI number — BARBARA JEAN BOUTELLE CARLSBAD PHYSICAL THERAPY

Table of content: (NPI 1255007050)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255007050 NPI number — BARBARA JEAN BOUTELLE CARLSBAD PHYSICAL THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BARBARA JEAN BOUTELLE CARLSBAD PHYSICAL THERAPY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255007050
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3070 MADISON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARLSBAD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92008-2310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-591-7750
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
467 COLLEGE BLVD STE 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OCEANSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92057-5436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-295-5156
Provider Business Practice Location Address Fax Number:
760-295-5146
Provider Enumeration Date:
08/20/2021

Additional Information

Authorized Official

Authorized Official Last Name:
BOUTELLE
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
SECRETARY/OWNER
Authorized Official Telephone Number:
760-591-7750

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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