Provider Demographics
NPI:1902573322
Name:KRIVICKAS, DYLAN M (DPT)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:M
Last Name:KRIVICKAS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 LYNDON FARM CT STE 300
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5005
Mailing Address - Country:US
Mailing Address - Phone:951-335-9825
Mailing Address - Fax:951-666-5096
Practice Address - Street 1:25136 HANCOCK AVE STE A
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-0905
Practice Address - Country:US
Practice Address - Phone:951-696-7474
Practice Address - Fax:951-696-7575
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT6027225100000X
CA303041225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist