Provider Demographics
NPI:1619273992
Name:BERNARD, BRIAN KEITH (PTA)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:KEITH
Last Name:BERNARD
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1557 RUBY DR
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-2919
Mailing Address - Country:US
Mailing Address - Phone:951-623-3126
Mailing Address - Fax:
Practice Address - Street 1:1557 RUBY DR
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-2919
Practice Address - Country:US
Practice Address - Phone:951-623-3126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-02
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6483225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant