1336500859 NPI number — MRS. GILLIAN VIRGINIA BANTIS PT, DPT, OCS

Table of content: MRS. GILLIAN VIRGINIA BANTIS PT, DPT, OCS (NPI 1336500859)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336500859 NPI number — MRS. GILLIAN VIRGINIA BANTIS PT, DPT, OCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BANTIS
Provider First Name:
GILLIAN
Provider Middle Name:
VIRGINIA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT, OCS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FOLEY
Provider Other First Name:
GILLIAN
Provider Other Middle Name:
VIRGINIA
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT, DPT, OCS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1336500859
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3230 E. IMPERIAL HWY.
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
BREA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92821-6735
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-988-8110
Provider Business Mailing Address Fax Number:
714-988-8111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 E. YALE LOOP
Provider Second Line Business Practice Location Address:
STE. 201
Provider Business Practice Location Address City Name:
IRVINE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-265-2442
Provider Business Practice Location Address Fax Number:
949-265-2448
Provider Enumeration Date:
03/10/2016

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:  PT291221 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: 291221 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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