Provider Demographics
NPI:1104920636
Name:BALDERAS, CHRISTINE YVONNE (PT)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:YVONNE
Last Name:BALDERAS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 TIERRA DEL REY
Mailing Address - Street 2:#C
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-7875
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1055 TIERRA DEL REY
Practice Address - Street 2:#C
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-7875
Practice Address - Country:US
Practice Address - Phone:619-656-5102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT149112251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT14911OtherPHYSICAL THERAPY LICENSE
CAWPT14911AMedicare ID - Type UnspecifiedPPIN
CAW17066Medicare ID - Type UnspecifiedMEDICARE GROUP