Provider Demographics
NPI:1801973540
Name:BLANCO, BRIAN PAUL (PT, DPT)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:PAUL
Last Name:BLANCO
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1800 E LAMBERT RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-4370
Mailing Address - Country:US
Mailing Address - Phone:714-256-5074
Mailing Address - Fax:714-256-0770
Practice Address - Street 1:755 N SHEPARD ST
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-2836
Practice Address - Country:US
Practice Address - Phone:714-630-6252
Practice Address - Fax:714-630-6048
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32518225100000X
CAPT32518225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ66779Medicare UPIN