Healthcare Provider Details

I. General information

NPI: 1639624497
Provider Name (Legal Business Name): MATTHEW JAMES BAUDENDISTEL DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2016
Last Update Date: 08/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3609 MISSION AVE SUITE C
CARMICHAEL CA
95608-2955
US

IV. Provider business mailing address

3609 MISSION AVE SUITE C
CARMICHAEL CA
95608-2955
US

V. Phone/Fax

Practice location:
  • Phone: 916-487-4681
  • Fax:
Mailing address:
  • Phone: 916-487-4681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number291948
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: