Healthcare Provider Details

I. General information

NPI: 1306770490
Provider Name (Legal Business Name): DEANDRE MEDLOCK PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 GOLDEN CENTER DR STE B
PLACERVILLE CA
95667-6278
US

IV. Provider business mailing address

4304 DEERGRASS ST
RANCHO CORDOVA CA
95742-8278
US

V. Phone/Fax

Practice location:
  • Phone: 530-344-2045
  • Fax: 530-642-0794
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number53465
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: