Provider Demographics
NPI:1063496289
Name:WAITE, JOHN ROBERT (PT DPT OCS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:WAITE
Suffix:
Gender:M
Credentials:PT DPT OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26383 ABELIA ST
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-4458
Mailing Address - Country:US
Mailing Address - Phone:951-514-7868
Mailing Address - Fax:
Practice Address - Street 1:25495 MEDICAL CENTER DR STE 304
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-4904
Practice Address - Country:US
Practice Address - Phone:951-696-7474
Practice Address - Fax:951-696-7575
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2018-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA168202251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP01284430OtherRR MEDICARE
CACA150811Medicare PIN
CACB232725Medicare PIN
CACA103958Medicare PIN
CAP01284430OtherRR MEDICARE
CACB232725Medicare PIN