Healthcare Provider Details

I. General information

NPI: 1568626570
Provider Name (Legal Business Name): NOVIE TAMBONG MIJARES PHYSICAL THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2008
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 SANDPOINT DR
RODEO CA
94572-1933
US

IV. Provider business mailing address

1020 SANDPOINT DR
RODEO CA
94572-1933
US

V. Phone/Fax

Practice location:
  • Phone: 510-374-9560
  • Fax:
Mailing address:
  • Phone: 510-374-9560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number32605
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: