Provider Demographics
NPI:1942879515
Name:NGUYEN, BAO PHUC
Entity Type:Individual
Prefix:
First Name:BAO
Middle Name:PHUC
Last Name:NGUYEN
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 1:5252 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-4913
Mailing Address - Country:US
Mailing Address - Phone:619-632-2476
Mailing Address - Fax:
Practice Address - Street 1:4541 PHILADELPHIA ST STE C103
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-2250
Practice Address - Country:US
Practice Address - Phone:909-590-7997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300348225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist