Healthcare Provider Details

I. General information

NPI: 1538268016
Provider Name (Legal Business Name): EILEEN R KALK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 12/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4135 MAIN ST
KELSEYVILLE CA
95451-8941
US

IV. Provider business mailing address

975 PAGE DR
LAKEPORT CA
95453-3419
US

V. Phone/Fax

Practice location:
  • Phone: 707-279-1888
  • Fax:
Mailing address:
  • Phone: 707-263-1855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number17682
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT10212
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: