Provider Demographics
NPI:1275268203
Name:LETTS, LUSTAN ORLANDO JR (PTA)
Entity Type:Individual
Prefix:
First Name:LUSTAN
Middle Name:ORLANDO
Last Name:LETTS
Suffix:JR
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 1:16270 HERITAGE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-5221
Mailing Address - Country:US
Mailing Address - Phone:951-237-8304
Mailing Address - Fax:
Practice Address - Street 1:2390 E FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92544-4707
Practice Address - Country:US
Practice Address - Phone:951-765-1474
Practice Address - Fax:951-765-1476
Is Sole Proprietor?:No
Enumeration Date:2022-07-22
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5501225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant