Provider Demographics
NPI:1316473309
Name:BOCKHOLT, JUSTIN ROBERT
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ROBERT
Last Name:BOCKHOLT
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 1:1158 QUINCE AVE
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087-2321
Mailing Address - Country:US
Mailing Address - Phone:408-505-7244
Mailing Address - Fax:
Practice Address - Street 1:1158 QUINCE AVE
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94087-2321
Practice Address - Country:US
Practice Address - Phone:408-505-7244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF48861052255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer