Provider Demographics
NPI:1154861482
Name:EATON, MICHAEL (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:EATON
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 1:885 CANARIOS CT STE 110
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-7877
Mailing Address - Country:US
Mailing Address - Phone:619-656-5102
Mailing Address - Fax:
Practice Address - Street 1:955 LANE AVE STE 201
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914-4525
Practice Address - Country:US
Practice Address - Phone:619-421-9521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-06
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT2929072251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT292907OtherPT LICENSE