Provider Demographics
NPI:1306929484
Name:MAILLARD, RENE ANDRE (PT)
Entity type:Individual
Prefix:
First Name:RENE
Middle Name:ANDRE
Last Name:MAILLARD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 STANDIFORD AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-1159
Mailing Address - Country:US
Mailing Address - Phone:209-579-5628
Mailing Address - Fax:209-579-5637
Practice Address - Street 1:1191 E YOSEMITE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-5011
Practice Address - Country:US
Practice Address - Phone:209-824-9888
Practice Address - Fax:209-824-9469
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT24674225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00160372OtherRAIL ROAD MEDICARE
CA0PT246740OtherBLUE SHIELD
CAP00160372OtherRAIL ROAD MEDICARE