Provider Demographics
NPI:1386957413
Name:ORTIZ, RICHARD CHARLES (PT)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:CHARLES
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22908 WREN ST
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5580
Mailing Address - Country:US
Mailing Address - Phone:951-990-6578
Mailing Address - Fax:909-614-7049
Practice Address - Street 1:22908 WREN ST
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5580
Practice Address - Country:US
Practice Address - Phone:951-990-6578
Practice Address - Fax:909-614-7049
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-18
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6456225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FR021ZMedicare UPIN