Provider Demographics
NPI:1710400213
Name:DOUGLAS, CHRISTINE (ATC)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22411 RIDGEBROOK
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-4531
Mailing Address - Country:US
Mailing Address - Phone:678-294-8298
Mailing Address - Fax:
Practice Address - Street 1:16566 NEWHOPE ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-2403
Practice Address - Country:US
Practice Address - Phone:714-663-6554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-17
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
110002301OtherNATA BOC