Healthcare Provider Details

I. General information

NPI: 1376799676
Provider Name (Legal Business Name): ILENIA PEREZ P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 05/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 E HERNDON AVE
FRESNO CA
93720-3391
US

IV. Provider business mailing address

8302 ESPRESSO DR STE 100
BAKERSFIELD CA
93312-5688
US

V. Phone/Fax

Practice location:
  • Phone: 559-256-5200
  • Fax: 559-256-5376
Mailing address:
  • Phone: 661-377-1700
  • Fax: 661-616-9199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT34619
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberPT34619
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT34619
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: