Healthcare Provider Details

I. General information

NPI: 1104997212
Provider Name (Legal Business Name): FRANK FOGAL PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 MCHENRY AVE STE 500
MODESTO CA
95350-4568
US

IV. Provider business mailing address

2609 BEATRICE LN
MODESTO CA
95355-9369
US

V. Phone/Fax

Practice location:
  • Phone: 209-575-5801
  • Fax: 209-575-0115
Mailing address:
  • Phone: 209-551-3820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number21525
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: