Healthcare Provider Details

I. General information

NPI: 1073237012
Provider Name (Legal Business Name): CHESTER FRANK KUTZLEB V
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 10/05/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3620 W HAMMER LN
STOCKTON CA
95219-5532
US

IV. Provider business mailing address

PO BOX 399318
SAN FRANCISCO CA
94139-9318
US

V. Phone/Fax

Practice location:
  • Phone: 866-523-4268
  • Fax:
Mailing address:
  • Phone: 866-523-4268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: