Basic Information
| Provider Information | |||||||||
| NPI: | 1902475700 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAMETA | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 380 STEVENS AVE STE 314 | ||||||||
| Address2: | |||||||||
| City: | SOLANA BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920752069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8587555200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 760 13TH ST | ||||||||
| Address2: | |||||||||
| City: | IMPERIAL BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919322308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8587555200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2021 | ||||||||
| LastUpdateDate: | 06/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 299728 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.