Healthcare Provider Details

I. General information

NPI: 1952665879
Provider Name (Legal Business Name): GRACITA KALLOS CLEMENA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GRACE CLEMENA PT

II. Dates (important events)

Enumeration Date: 06/26/2012
Last Update Date: 06/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 W REFINADO WAY
MOUNTAIN HOUSE CA
95391-3002
US

IV. Provider business mailing address

675 W REFINADO WAY
MOUNTAIN HOUSE CA
95391-3002
US

V. Phone/Fax

Practice location:
  • Phone: 386-846-3521
  • Fax:
Mailing address:
  • Phone: 386-846-3521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number38300
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: