Provider Demographics
NPI:1114147055
Name:PRANTE, ERIC STAFFORD (PT)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:STAFFORD
Last Name:PRANTE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5360 JACKSON DR STE 110
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3012
Mailing Address - Country:US
Mailing Address - Phone:619-667-7000
Mailing Address - Fax:619-667-4315
Practice Address - Street 1:5360 JACKSON DR STE 110
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3012
Practice Address - Country:US
Practice Address - Phone:619-667-7000
Practice Address - Fax:619-667-4315
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT10428225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1023103330OtherPRACTICE NPI
CA1023103330OtherPRACTICE NPI