Healthcare Provider Details

I. General information

NPI: 1215402185
Provider Name (Legal Business Name): KRISTOPHER KEVIN CABALLERO BALUYOT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2018
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 N BRAND BLVD STE 208
GLENDALE CA
91203-2627
US

IV. Provider business mailing address

130 N BRAND BLVD STE 208
GLENDALE CA
91203-2627
US

V. Phone/Fax

Practice location:
  • Phone: 818-945-6003
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2279P3900X
TaxonomyNeonatal/Pediatric Registered Respiratory Therapist
License Number26505
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: