=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659510667
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROMY VALLEJO VILLALUZ PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2009
-----------------------------------------------------
Last Update Date | 02/13/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4860 Y ST STE 1100
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95817-2307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-734-3437
-----------------------------------------------------
Fax | 916-454-2703
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4860 Y ST STE 1100
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95817-2307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | AT8261
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------