Provider Demographics
NPI:1255421319
Name:ITO, CARL (RPT)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:ITO
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1562 RUBENSTEIN AVE
Mailing Address - Street 2:
Mailing Address - City:CARDIFF
Mailing Address - State:CA
Mailing Address - Zip Code:92007-2436
Mailing Address - Country:US
Mailing Address - Phone:619-464-1352
Mailing Address - Fax:619-464-7255
Practice Address - Street 1:8939 LA MESA BLVD
Practice Address - Street 2:STE 1
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-9057
Practice Address - Country:US
Practice Address - Phone:619-464-1352
Practice Address - Fax:619-464-7255
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT011245225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT011245OtherREG PHYSICAL THERAPIST