Healthcare Provider Details

I. General information

NPI: 1801130299
Provider Name (Legal Business Name): PRAVEEN KUMAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 11/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2724 ACAPULCO WAY
MODESTO CA
95355-8733
US

IV. Provider business mailing address

2724 ACAPULCO WAY
MODESTO CA
95355-8733
US

V. Phone/Fax

Practice location:
  • Phone: 209-722-8208
  • Fax:
Mailing address:
  • Phone: 209-722-8208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberAT 8650
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: