Basic Information
Provider Information | |||||||||
NPI: | 1306929484 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MAILLARD | ||||||||
FirstName: | RENE | ||||||||
MiddleName: | ANDRE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.T. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 220 STANDIFORD AVE | ||||||||
Address2: | SUITE F | ||||||||
City: | MODESTO | ||||||||
State: | CA | ||||||||
PostalCode: | 953501159 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2095795628 | ||||||||
FaxNumber: | 2095795637 | ||||||||
Practice Location | |||||||||
Address1: | 1191 E YOSEMITE AVE | ||||||||
Address2: | SUITE A | ||||||||
City: | MANTECA | ||||||||
State: | CA | ||||||||
PostalCode: | 953365011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2098249888 | ||||||||
FaxNumber: | 2098249469 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/23/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT24674 | CA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | P00160372 | 01 | CA | RAIL ROAD MEDICARE | OTHER | 0PT246740 | 01 | CA | BLUE SHIELD | OTHER |