Healthcare Provider Details

I. General information

NPI: 1932398450
Provider Name (Legal Business Name): SHYAM ULLAL,PT A PROF.CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2007
Last Update Date: 11/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 E 3RD ST SUITE F
CALEXICO CA
92231-2854
US

IV. Provider business mailing address

2330 SANDALWOOD DRIVE
EL CENTRO CA
92243-3674
US

V. Phone/Fax

Practice location:
  • Phone: 760-357-8864
  • Fax: 760-357-8866
Mailing address:
  • Phone: 760-357-8864
  • Fax: 760-357-8866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT 10423
License Number StateCA

VIII. Authorized Official

Name: MR. SHYAM S ULLAL
Title or Position: CEO/OWNER
Credential: P.T.
Phone: 760-357-8864