Provider Demographics
NPI:1164738076
Name:YARDIMIAN, CAROLYN BULLARD (DPT)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:BULLARD
Last Name:YARDIMIAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:CORINNE
Other - Last Name:BULLARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24630 WASHINGTON AVE
Mailing Address - Street 2:STE. 200
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-6177
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:886 MAGNOLIA AVE
Practice Address - Street 2:STE. 100
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3105
Practice Address - Country:US
Practice Address - Phone:951-340-3402
Practice Address - Fax:951-340-3416
Is Sole Proprietor?:No
Enumeration Date:2010-08-30
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT37123225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT371230OtherBLUE SHIELD OF CALIFORNIA
CAEA957ZMedicare PIN
CAEA957UMedicare PIN
CAW17215BMedicare PIN