Basic Information
| Provider Information | |||||||||
| NPI: | 1124205125 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AULD | ||||||||
| FirstName: | BRODIE | ||||||||
| MiddleName: | GLEN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1045 LAS GALLINAS AVE | ||||||||
| Address2: | |||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949032464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102132700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4655 RUFFNER ST | ||||||||
| Address2: | SUITE 270 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007876787 | ||||||||
| FaxNumber: | 8007876762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2008 | ||||||||
| LastUpdateDate: | 02/15/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT13675 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.