=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548345390
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MITCHELL KAUK PT OCS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2006
-----------------------------------------------------
Last Update Date | 05/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 224A WELLER ST
-----------------------------------------------------
City | PETALUMA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94952-3136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-762-7678
-----------------------------------------------------
Fax | 707-762-7679
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 224A WELLER ST
-----------------------------------------------------
City | PETALUMA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94952-3136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-762-7678
-----------------------------------------------------
Fax | 707-762-7679
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | PT10959
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------