Healthcare Provider Details

I. General information

NPI: 1619748696
Provider Name (Legal Business Name): MARIO PEREZ DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2024
Last Update Date: 01/10/2024
Certification Date: 01/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6759 SIERRA CT STE A
DUBLIN CA
94568-2657
US

IV. Provider business mailing address

625 KENMOOR AVE SE STE 100
GRAND RAPIDS MI
49546-2395
US

V. Phone/Fax

Practice location:
  • Phone: 925-803-0530
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: