Provider Demographics
NPI:1528215688
Name:AGEE, JUSTIN NEAL (PT)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:NEAL
Last Name:AGEE
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 1:624 SONJA AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-3437
Mailing Address - Country:US
Mailing Address - Phone:760-793-6262
Mailing Address - Fax:
Practice Address - Street 1:1081 N CHINA LAKE BLVD
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-3130
Practice Address - Country:US
Practice Address - Phone:760-793-6262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30183225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist