Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251S0007X | Physical Therapist - Sports | PT23941 | CA |
NPI | 1003450453 |
---|---|
Provider Name | Jon Garrelts |
First Address | San Diego, CA 92127-5705 |
Second Address | San Diego, CA 92128-3491 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/10/2019 |
Last Update Date | 27/12/2021 |