Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0019X | Occupational Therapist - Physical Rehabilitation | 13891 | CA |
NPI | 1396141164 |
---|---|
Provider Name | Mr. Reynaldo Ballesteros JR. |
First Address | Vallejo, CA 94591-8523 |
Second Address | Vallejo, CA 94591-8523 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/11/2014 |
Last Update Date | 06/11/2014 |