Provider Demographics
NPI:1023577491
Name:TEETS, CAROLINE A
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:A
Last Name:TEETS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2777 BRISTOL ST STE B
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-5997
Mailing Address - Country:US
Mailing Address - Phone:951-440-1916
Mailing Address - Fax:
Practice Address - Street 1:2777 BRISTOL ST STE B
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5997
Practice Address - Country:US
Practice Address - Phone:949-250-1112
Practice Address - Fax:949-250-1404
Is Sole Proprietor?:No
Enumeration Date:2019-03-15
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT296320225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist