Provider Demographics
NPI:1326586975
Name:FRUTO, JUAN CARLO
Entity Type:Individual
Prefix:
First Name:JUAN CARLO
Middle Name:
Last Name:FRUTO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41024 SUNSPRITE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92532-1556
Mailing Address - Country:US
Mailing Address - Phone:951-575-9768
Mailing Address - Fax:
Practice Address - Street 1:41024 SUNSPRITE ST
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92532-1556
Practice Address - Country:US
Practice Address - Phone:951-575-9768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-03
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41851225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist