Healthcare Provider Details

I. General information

NPI: 1144425877
Provider Name (Legal Business Name): FERNANDO PALIS CABLING OTRL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: GRADY PALIS CABLING OTRL

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 10/23/2021
Certification Date: 10/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4510 VIEWRIDGE AVE
SAN DIEGO CA
92123-1637
US

IV. Provider business mailing address

721 BAYLOR AVE
BONITA CA
91902-4029
US

V. Phone/Fax

Practice location:
  • Phone: 858-694-4977
  • Fax:
Mailing address:
  • Phone: 619-421-8656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number1374
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: