Healthcare Provider Details

I. General information

NPI: 1194324178
Provider Name (Legal Business Name): KALLI ANN WILKENS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2020
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 S MOUNT VERNON AVE STE 400
COLTON CA
92324-3928
US

IV. Provider business mailing address

PO BOX 10016
REDLANDS CA
92375-3216
US

V. Phone/Fax

Practice location:
  • Phone: 909-370-3396
  • Fax: 909-783-4288
Mailing address:
  • Phone: 909-883-5069
  • Fax: 909-883-5473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number299139
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: