Healthcare Provider Details

I. General information

NPI: 1366796211
Provider Name (Legal Business Name): PETER PEREZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2012
Last Update Date: 10/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1539 MCHENRY AVE
MODESTO CA
95350-4528
US

IV. Provider business mailing address

704 COLUMBIA WAY
MODESTO CA
95350-5962
US

V. Phone/Fax

Practice location:
  • Phone: 209-578-3290
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5189
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: