Provider Demographics
NPI:1437971371
Name:BURGOS, CAROL
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:BURGOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 VIA VICINI
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-3882
Mailing Address - Country:US
Mailing Address - Phone:714-757-8114
Mailing Address - Fax:
Practice Address - Street 1:30492 GATEWAY PL STE 201
Practice Address - Street 2:
Practice Address - City:RANCHO MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92694-1899
Practice Address - Country:US
Practice Address - Phone:949-877-7745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-31
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9519225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant