Provider Demographics
NPI:1013377639
Name:BANTIGUE, DAPHNE FAJAYAN (BS, DPT)
Entity Type:Individual
Prefix:DR
First Name:DAPHNE
Middle Name:FAJAYAN
Last Name:BANTIGUE
Suffix:
Gender:F
Credentials:BS, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 BRUNSWICK CIR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-6119
Mailing Address - Country:US
Mailing Address - Phone:909-762-4443
Mailing Address - Fax:
Practice Address - Street 1:2900 BRUNSWICK CIR
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-6119
Practice Address - Country:US
Practice Address - Phone:909-762-4443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-24
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40866225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist