Healthcare Provider Details

I. General information

NPI: 1740007806
Provider Name (Legal Business Name): MITCHELL MCKINLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2024
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3097 MOORPARK AVE STE 100
SAN JOSE CA
95128-2543
US

IV. Provider business mailing address

1410 OAK ST STE 100
EUGENE OR
97401-4668
US

V. Phone/Fax

Practice location:
  • Phone: 669-247-6170
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: