Provider Demographics
NPI:1619671609
Name:HAGAN, RACHEL S (PTA)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:S
Last Name:HAGAN
Suffix:
Gender:F
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:PO BOX 1699
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-1699
Mailing Address - Country:US
Mailing Address - Phone:909-567-5015
Mailing Address - Fax:
Practice Address - Street 1:25590 PROSPECT AVE APT 30H
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3151
Practice Address - Country:US
Practice Address - Phone:909-567-5015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTA48504225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant