Basic Information
| Provider Information | |||||||||
| NPI: | 1992421200 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUMILAT | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | JAMES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3053 PRADO LN | ||||||||
| Address2: | |||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923249545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098243126 | ||||||||
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| Practice Location | |||||||||
| Address1: | 17270 BEAR VALLEY RD STE 105 | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923957751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602458828 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2022 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 303032 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.