Provider Demographics
NPI:1578002820
Name:JOSEPH M MONDRY
Entity type:Organization
Organization Name:JOSEPH M MONDRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:M
Authorized Official - Last Name:MONDRY
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, MSRS, CSCS, CLT
Authorized Official - Phone:619-415-5817
Mailing Address - Street 1:3079 SPRUCEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92027-6723
Mailing Address - Country:US
Mailing Address - Phone:760-613-6044
Mailing Address - Fax:
Practice Address - Street 1:2535 TRUXTUN RD STE 208
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-6160
Practice Address - Country:US
Practice Address - Phone:619-415-5817
Practice Address - Fax:619-934-9581
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOSEPH M MONDRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-20
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT20030225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty