Healthcare Provider Details

I. General information

NPI: 1730691627
Provider Name (Legal Business Name): JOHN KUDREYKO III PT,DPT,CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2017
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 E OCEAN AVE
LOMPOC CA
93436-7081
US

IV. Provider business mailing address

2064 MILKY WAY CIR
ROSEVILLE CA
95747-8467
US

V. Phone/Fax

Practice location:
  • Phone: 805-735-8365
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number3614
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT294289
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: