Provider Demographics
NPI:1922648245
Name:BRISTOL, BRISTOL LEE (PTA)
Entity Type:Individual
Prefix:
First Name:BRISTOL
Middle Name:LEE
Last Name:BRISTOL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:581 N PAGEANT DR UNIT E
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92869-2537
Mailing Address - Country:US
Mailing Address - Phone:817-694-8444
Mailing Address - Fax:
Practice Address - Street 1:1026 E CHAPMAN AVE STE C
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-2152
Practice Address - Country:US
Practice Address - Phone:714-538-1953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50340225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant