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General NPI Number Information
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NPI Number | 1255193579
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Entity Type | Individual
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Provider Name | DEVALLEE PEDROGO PTA
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Gender | Male
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Dates
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Enumeration Date | 01/24/2024
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Last Update Date | 01/24/2024
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Provider Practice Location Address
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Address Line | 22342 EL PASEO STE G
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City | RANCHO SANTA MARGARITA
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State | CA
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Zip | 92688-5804
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Country | US
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Telephone | 949-876-5329
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Fax |
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Provider Business Mailing Address
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Address Line | 26655 AVENIDA DESEO
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City | MISSION VIEJO
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State | CA
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Zip | 92691-4301
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 53093
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License Number State | CA
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