Provider Demographics
NPI:1720556400
Name:NGUYEN, BRIAN DUC-BAO (DPT)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DUC-BAO
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2964 GAMBREL GATE
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-2372
Mailing Address - Country:US
Mailing Address - Phone:909-732-6978
Mailing Address - Fax:
Practice Address - Street 1:1902 ROYALTY DR STE 170
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3030
Practice Address - Country:US
Practice Address - Phone:909-620-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-11
Last Update Date:2018-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA295864225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty