1700576865 NPI number — KRISTEN DIBERNARDO DPT

Table of content: KRISTEN DIBERNARDO DPT (NPI 1700576865)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700576865 NPI number — KRISTEN DIBERNARDO DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIBERNARDO
Provider First Name:
KRISTEN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1700576865
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3018 DELUNA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RANCHO PALOS VERDES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90275-6303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-606-1715
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
890 SHASTA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORRO BAY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93442-1933
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-772-4325
Provider Business Practice Location Address Fax Number:
805-772-2886
Provider Enumeration Date:
05/11/2023

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:  27531 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 304040 , 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)





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