Provider Demographics
NPI:1740934967
Name:REBULTAN, EARL FRANK (PTA)
Entity type:Individual
Prefix:
First Name:EARL FRANK
Middle Name:
Last Name:REBULTAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:EARL
Other - Middle Name:
Other - Last Name:REBULTAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:11466 LEV AVE
Mailing Address - Street 2:
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91345-1229
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11466 LEV AVE
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-1229
Practice Address - Country:US
Practice Address - Phone:818-282-0120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9587225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant