Provider Demographics
NPI:1598792871
Name:GJERTSEN, BRUCE (RPT)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:GJERTSEN
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 HAMMOND STE C
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-1680
Mailing Address - Country:US
Mailing Address - Phone:949-770-6022
Mailing Address - Fax:
Practice Address - Street 1:18643 BROOKHURST ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-6709
Practice Address - Country:US
Practice Address - Phone:714-962-3867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT5937225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist