Provider Demographics
NPI:1225571177
Name:RETUYA, ERICO (PTA)
Entity Type:Individual
Prefix:
First Name:ERICO
Middle Name:
Last Name:RETUYA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 PASEO ENTRADA
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-6724
Mailing Address - Country:US
Mailing Address - Phone:858-229-1809
Mailing Address - Fax:
Practice Address - Street 1:1009 PASEO ENTRADA
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-6724
Practice Address - Country:US
Practice Address - Phone:858-229-1809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-27
Last Update Date:2016-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10309225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant