Healthcare Provider Details

I. General information

NPI: 1003247644
Provider Name (Legal Business Name): SHAREN N CHEATHON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2013
Last Update Date: 12/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W TURNER RD SUITE 250
LODI CA
95242-2182
US

IV. Provider business mailing address

1106 WALNUT ST SUITE 110
SAN LUIS OBISPO CA
93401-2416
US

V. Phone/Fax

Practice location:
  • Phone: 209-334-2224
  • Fax: 209-334-2225
Mailing address:
  • Phone: 805-788-0805
  • Fax: 805-788-0845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT40730
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: