Provider Demographics
NPI:1659849073
Name:WIMBOPRASETYO, WURI TRIHASTUTI (RCP)
Entity Type:Individual
Prefix:
First Name:WURI
Middle Name:TRIHASTUTI
Last Name:WIMBOPRASETYO
Suffix:
Gender:F
Credentials:RCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36853 BAY HILL DR
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-8015
Mailing Address - Country:US
Mailing Address - Phone:661-210-6227
Mailing Address - Fax:
Practice Address - Street 1:27300 IRIS AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-4802
Practice Address - Country:US
Practice Address - Phone:951-243-0811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-02
Last Update Date:2018-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38700227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered