Basic Information
| Provider Information | |||||||||
| NPI: | 1548407133 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KORNBLATT | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 E BIDWELL ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | FOLSOM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956303452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169835915 | ||||||||
| FaxNumber: | 9169835932 | ||||||||
| Practice Location | |||||||||
| Address1: | 715 POLE LINE RD | ||||||||
| Address2: | |||||||||
| City: | DAVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956184015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307564900 | ||||||||
| FaxNumber: | 5307564290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2009 | ||||||||
| LastUpdateDate: | 01/19/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 12918 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.