Provider Demographics
NPI:1649668302
Name:LEQUIA, BRYAN (RPT)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:LEQUIA
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 1:47616 WILLOW POND RD
Mailing Address - Street 2:
Mailing Address - City:COARSEGOLD
Mailing Address - State:CA
Mailing Address - Zip Code:93614-9134
Mailing Address - Country:US
Mailing Address - Phone:949-201-8946
Mailing Address - Fax:
Practice Address - Street 1:47616 WILLOW POND RD
Practice Address - Street 2:
Practice Address - City:COARSEGOLD
Practice Address - State:CA
Practice Address - Zip Code:93614-9134
Practice Address - Country:US
Practice Address - Phone:949-201-8946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 26186225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist