Healthcare Provider Details

I. General information

NPI: 1598073397
Provider Name (Legal Business Name): MEREDITH LESLIE ERIN FRUCHTENICHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2010
Last Update Date: 09/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 OLD CROW CANYON RD BUILDING 100 SUITE 112
SAN RAMON CA
94583-1623
US

IV. Provider business mailing address

2500 OLD CROW CANYON RD BUILDING 100 SUITE 112
SAN RAMON CA
94583-1623
US

V. Phone/Fax

Practice location:
  • Phone: 925-362-0683
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT26775
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: