Provider Demographics
NPI:1245789080
Name:FRACALOSY, JEFFREY (DPT)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:FRACALOSY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 DE ANZA DR
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-2606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2600 E COAST HWY
Practice Address - Street 2:
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625-2117
Practice Address - Country:US
Practice Address - Phone:949-640-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05482612251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic