Provider Demographics
NPI:1790746659
Name:ANDERSON, BRIAN JON (MSPT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JON
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24630 WASHINGTON AVE
Mailing Address - Street 2:STE. 200
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-6131
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:10020 INDIANA AVE
Practice Address - Street 2:STE. 4
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-5477
Practice Address - Country:US
Practice Address - Phone:951-637-2320
Practice Address - Fax:951-637-2321
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT-26276225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGT201UMedicare PIN
CAGT201QMedicare PIN