Provider Demographics
NPI:1780228718
Name:MA, DAO THANH
Entity Type:Individual
Prefix:
First Name:DAO
Middle Name:THANH
Last Name:MA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40138 CALLE REAL
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-5909
Mailing Address - Country:US
Mailing Address - Phone:626-864-4344
Mailing Address - Fax:
Practice Address - Street 1:28975 OLD TOWN FRONT ST STE 201
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-2863
Practice Address - Country:US
Practice Address - Phone:909-260-1159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-02
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA297565225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist