Healthcare Provider Details

I. General information

NPI: 1700499787
Provider Name (Legal Business Name): MARVIN E ALLAM PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 08/28/2020
Certification Date: 08/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15215 NATIONAL AVE STE 100
LOS GATOS CA
95032-2425
US

IV. Provider business mailing address

575 W HACIENDA AVE APT 214
CAMPBELL CA
95008-6551
US

V. Phone/Fax

Practice location:
  • Phone: 408-358-7326
  • Fax:
Mailing address:
  • Phone: 832-344-7950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number50780
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: