Provider Demographics
NPI:1902142318
Name:CACERES, JORGE BASTIDAS (PT, MPT)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:BASTIDAS
Last Name:CACERES
Suffix:
Gender:M
Credentials:PT, MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2275 S MAIN ST
Mailing Address - Street 2:102
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-5303
Mailing Address - Country:US
Mailing Address - Phone:951-273-7742
Mailing Address - Fax:
Practice Address - Street 1:2275 S MAIN ST
Practice Address - Street 2:102
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-5303
Practice Address - Country:US
Practice Address - Phone:951-273-7742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-13
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
CAPT356902251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic