Healthcare Provider Details

I. General information

NPI: 1447176425
Provider Name (Legal Business Name): KELSI MADISON VASQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1019 S MAIN ST
MANTECA CA
95337-5703
US

IV. Provider business mailing address

1019 S MAIN ST
MANTECA CA
95337-5703
US

V. Phone/Fax

Practice location:
  • Phone: 209-508-9573
  • Fax:
Mailing address:
  • Phone: 209-508-9573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number310322
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: