Healthcare Provider Details

I. General information

NPI: 1912983156
Provider Name (Legal Business Name): DAVID RUSSELL JANBAZ PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4860 Y ST
SACRAMENTO CA
95817-2307
US

IV. Provider business mailing address

1137 RUDGWICK DR
ROSEVILLE CA
95747-6453
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-6700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberAT 1786
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: