Provider Demographics
NPI:1578076097
Name:ENAYATI, NIMA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:NIMA
Middle Name:
Last Name:ENAYATI
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11800 CARMEL CREEK RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2675
Mailing Address - Country:US
Mailing Address - Phone:925-577-3815
Mailing Address - Fax:
Practice Address - Street 1:65 E WADSWORTH PARK DR STE 230
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-8096
Practice Address - Country:US
Practice Address - Phone:385-308-8034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA294009225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist