Healthcare Provider Details

I. General information

NPI: 1518843291
Provider Name (Legal Business Name): KIMBERLY TJANTRA
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2025
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 GRAND AVE STE 109
SAN DIEGO CA
92109-4047
US

IV. Provider business mailing address

910 GRAND AVE STE 109
SAN DIEGO CA
92109-4047
US

V. Phone/Fax

Practice location:
  • Phone: 858-283-8141
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number308637
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: