Provider Demographics
NPI:1407413511
Name:NGUYEN, KHA D (PT)
Entity Type:Individual
Prefix:
First Name:KHA
Middle Name:D
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 CENTRAL AVE STE C
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-2740
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:277 RANCHEROS DR STE 150
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-2976
Practice Address - Country:US
Practice Address - Phone:769-752-1011
Practice Address - Fax:760-752-1311
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-23
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT296670225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1407413511Medicaid
CACB348646OtherMEDICARE
CAPT296670OtherPT LICENSE