Healthcare Provider Details

I. General information

NPI: 1730633462
Provider Name (Legal Business Name): ROBERT A PACHECO DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2016
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 W ALAMEDA AVE SUITE 206
BURBANK CA
91505-4402
US

IV. Provider business mailing address

PO BOX 100 PMB 700
MAMMOTH LAKES CA
93546
US

V. Phone/Fax

Practice location:
  • Phone: 818-841-3936
  • Fax: 818-841-5974
Mailing address:
  • Phone: 760-924-4148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberPT291664
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: