Healthcare Provider Details

I. General information

NPI: 1144815663
Provider Name (Legal Business Name): THOMAS JAMES KRISKO PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2021
Last Update Date: 03/05/2021
Certification Date: 03/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79440 CORPORATE CENTER DR STE 112
LA QUINTA CA
92253-7243
US

IV. Provider business mailing address

118 ROSETTA CT
PALM DESERT CA
92211-0773
US

V. Phone/Fax

Practice location:
  • Phone: 760-771-9054
  • Fax:
Mailing address:
  • Phone: 619-592-0142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number51036
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: