=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770391120
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ISSIMA JAVON CALDWELL JR.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2024
-----------------------------------------------------
Last Update Date | 01/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1005 E PESCADERO AVE # SITE211
-----------------------------------------------------
City | TRACY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95304-8503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-767-2895
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2725 PAVILION PKWY APT 7216
-----------------------------------------------------
City | TRACY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95304-9590
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-767-2895
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174H00000X
-----------------------------------------------------
Taxonomy Name | Health Educator
-----------------------------------------------------
License Number | 1503552
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 224Y00000X
-----------------------------------------------------
Taxonomy Name | Clinical Exercise Physiologist
-----------------------------------------------------
License Number | 1503552
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 171400000X
-----------------------------------------------------
Taxonomy Name | Health & Wellness Coach
-----------------------------------------------------
License Number | 1503552
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------