Healthcare Provider Details

I. General information

NPI: 1336409085
Provider Name (Legal Business Name): TKB SPORTS MEDICINE & REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2012
Last Update Date: 10/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

356 DIGITAL DR
MORGAN HILL CA
95037-2879
US

IV. Provider business mailing address

10521 POTTS WAY
SAN JOSE CA
95111-3330
US

V. Phone/Fax

Practice location:
  • Phone: 408-440-2359
  • Fax: 408-890-4775
Mailing address:
  • Phone: 408-440-2359
  • Fax: 408-890-4775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number StateCA

VIII. Authorized Official

Name: JENNAH HUONG LE
Title or Position: OFFICE MANAGER
Credential:
Phone: 408-440-2359