Provider Demographics
NPI:1306528013
Name:TIELMAN, CALVIN DANIEL
Entity type:Individual
Prefix:
First Name:CALVIN
Middle Name:DANIEL
Last Name:TIELMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11464 VIA NORTE
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3839
Mailing Address - Country:US
Mailing Address - Phone:909-674-3879
Mailing Address - Fax:
Practice Address - Street 1:11464 VIA NORTE
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3839
Practice Address - Country:US
Practice Address - Phone:909-674-3879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50379225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant