Healthcare Provider Details

I. General information

NPI: 1245475748
Provider Name (Legal Business Name): ROGER MOLINA CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2008
Last Update Date: 02/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 E. ORANGEBURG AVENUE SUITE 102
MODESTO CA
95350-5512
US

IV. Provider business mailing address

1700 N. CHRISMAN ROAD
TRACY CA
95304-9314
US

V. Phone/Fax

Practice location:
  • Phone: 209-526-1721
  • Fax: 209-526-1740
Mailing address:
  • Phone: 209-526-1721
  • Fax: 209-526-1740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberCPO0057
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberCPO00577
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License NumberCPO0057
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: