Provider Demographics
NPI:1154499721
Name:BUSSELL, MARK R (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:BUSSELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:25455 BARTON RD STE 208A
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3177
Mailing Address - Country:US
Mailing Address - Phone:909-558-6799
Mailing Address - Fax:909-558-6513
Practice Address - Street 1:25455 BARTON RD STE 208A
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3177
Practice Address - Country:US
Practice Address - Phone:909-558-6799
Practice Address - Fax:909-558-6513
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC5207225100000X
CAPT16267225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist