Provider Demographics
NPI:1336976182
Name:SUMINISTRADO, BOBBY (PTA)
Entity type:Individual
Prefix:
First Name:BOBBY
Middle Name:
Last Name:SUMINISTRADO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25115 AVENUE STANFORD STE B135
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-1290
Mailing Address - Country:US
Mailing Address - Phone:661-250-9940
Mailing Address - Fax:661-250-9959
Practice Address - Street 1:4211 TIERRA REJADA RD
Practice Address - Street 2:
Practice Address - City:MOORPARK
Practice Address - State:CA
Practice Address - Zip Code:93021-3772
Practice Address - Country:US
Practice Address - Phone:805-529-8076
Practice Address - Fax:805-523-8796
Is Sole Proprietor?:No
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53568225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant