Healthcare Provider Details

I. General information

NPI: 1093347577
Provider Name (Legal Business Name): TANNER EMIL KUYPER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2020
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9852 BUSINESS PARK DR STE A
SACRAMENTO CA
95827-1709
US

IV. Provider business mailing address

5408 FOLSOM BLVD
SACRAMENTO CA
95819-4541
US

V. Phone/Fax

Practice location:
  • Phone: 916-362-7962
  • Fax:
Mailing address:
  • Phone: 530-356-4996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number297171
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: