Provider Demographics
NPI:1326514811
Name:WATERS, ANTHONY RAY (MPT)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:RAY
Last Name:WATERS
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25017 DORIA AVE
Mailing Address - Street 2:
Mailing Address - City:LOMITA
Mailing Address - State:CA
Mailing Address - Zip Code:90717-1707
Mailing Address - Country:US
Mailing Address - Phone:310-528-0733
Mailing Address - Fax:
Practice Address - Street 1:550 DEEP VALLEY DR
Practice Address - Street 2:
Practice Address - City:ROLLING HILLS ESTATES
Practice Address - State:CA
Practice Address - Zip Code:90274-3664
Practice Address - Country:US
Practice Address - Phone:310-544-6264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA188182251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic