Provider Demographics
NPI:1174313373
Name:BALLESTEROS, BRAIAN JONUE
Entity type:Individual
Prefix:
First Name:BRAIAN
Middle Name:JONUE
Last Name:BALLESTEROS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30428 HAUN RD STE 810
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-6824
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:
Practice Address - Street 1:521 E ELDER ST STE 106
Practice Address - Street 2:
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-3082
Practice Address - Country:US
Practice Address - Phone:760-723-8337
Practice Address - Fax:760-723-5476
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-09
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA307970225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist