Provider Demographics
NPI:1710684089
Name:BROMMER, RAINA
Entity Type:Individual
Prefix:
First Name:RAINA
Middle Name:
Last Name:BROMMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6636 DARKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-6527
Mailing Address - Country:US
Mailing Address - Phone:951-283-1675
Mailing Address - Fax:
Practice Address - Street 1:23623 SUNNYMEAD BLVD
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-0522
Practice Address - Country:US
Practice Address - Phone:951-221-3259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-08
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52237225200000X
225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant