1255811220 NPI number — CHEYENNE ROSE SPENCER PT, DPT

Table of content: CHEYENNE ROSE SPENCER PT, DPT (NPI 1255811220)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255811220 NPI number — CHEYENNE ROSE SPENCER PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPENCER
Provider First Name:
CHEYENNE
Provider Middle Name:
ROSE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1255811220
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/18/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3337 RED MOUNTAIN HEIGHTS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FALLBROOK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92028-9755
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-587-3631
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25495 MEDICAL CENTER DR STE 304
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MURRIETA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92562-4904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-696-7474
Provider Business Practice Location Address Fax Number:
951-696-7575
Provider Enumeration Date:
08/18/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  295354 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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