Healthcare Provider Details

I. General information

NPI: 1528947694
Provider Name (Legal Business Name): DEMOND SHORT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2025
Last Update Date: 09/05/2025
Certification Date: 09/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7224 S RECOVERY RD
FRENCH CAMP CA
95231-8901
US

IV. Provider business mailing address

7224 S RECOVERY RD
FRENCH CAMP CA
95231-8901
US

V. Phone/Fax

Practice location:
  • Phone: 209-888-6595
  • Fax: 209-888-6596
Mailing address:
  • Phone: 209-888-6595
  • Fax: 209-888-6596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License NumberY4352867
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: