Provider Demographics
NPI:1386386266
Name:KROTTMAYER, RICHARD J JR
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:KROTTMAYER
Suffix:JR
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 1:25311 ROBINSON CREEK LN
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-8436
Mailing Address - Country:US
Mailing Address - Phone:951-206-6331
Mailing Address - Fax:
Practice Address - Street 1:425 DIAMOND DR STE 101
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4495
Practice Address - Country:US
Practice Address - Phone:951-674-9515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-11
Last Update Date:2025-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA301939225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA301939OtherPHYSICAL THERAPY LICENSE