Healthcare Provider Details

I. General information

NPI: 1588052229
Provider Name (Legal Business Name): KENNETH G BURGDORFF P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2015
Last Update Date: 01/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 NEVADA AVE
EL MONTE CA
91733-2318
US

IV. Provider business mailing address

1923 W CORAK ST
WEST COVINA CA
91790-3228
US

V. Phone/Fax

Practice location:
  • Phone: 626-443-9425
  • Fax:
Mailing address:
  • Phone: 626-962-9702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT8164
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: