Provider Demographics
NPI:1346700218
Name:KUBO, BRYCE ROBERT (DPT)
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:ROBERT
Last Name:KUBO
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 1:28924 S WESTERN AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-0813
Mailing Address - Country:US
Mailing Address - Phone:310-548-0104
Mailing Address - Fax:
Practice Address - Street 1:28924 S WESTERN AVE STE 101
Practice Address - Street 2:
Practice Address - City:RANCHO PALOS VERDES
Practice Address - State:CA
Practice Address - Zip Code:90275-0813
Practice Address - Country:US
Practice Address - Phone:310-548-0104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT296463225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist