Healthcare Provider Details

I. General information

NPI: 1871773200
Provider Name (Legal Business Name): MICHAEL PODLENSKI PTA, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2007
Last Update Date: 11/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8881 FLETCHER PKWY SUITE #280
LA MESA CA
91942-3134
US

IV. Provider business mailing address

1891 FUERTE VALLEY DR
EL CAJON CA
92019-3739
US

V. Phone/Fax

Practice location:
  • Phone: 619-464-0105
  • Fax:
Mailing address:
  • Phone: 619-441-0192
  • Fax: 619-441-0193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberAT2570
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: