Healthcare Provider Details

I. General information

NPI: 1972205672
Provider Name (Legal Business Name): REBEKAH ROSE BALTIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 03/20/2023
Certification Date: 03/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 HOLLAND AVE
CLOVIS CA
93619-8936
US

IV. Provider business mailing address

3150 HOLLAND AVE
CLOVIS CA
93619-8936
US

V. Phone/Fax

Practice location:
  • Phone: 559-355-3824
  • Fax:
Mailing address:
  • Phone: 559-355-3824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number301837
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: