Provider Demographics
NPI:1992421200
Name:SUMILAT, JOHN JAMES
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:JAMES
Last Name:SUMILAT
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 1:3053 PRADO LN
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-9545
Mailing Address - Country:US
Mailing Address - Phone:909-824-3126
Mailing Address - Fax:
Practice Address - Street 1:17270 BEAR VALLEY RD STE 105
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-7751
Practice Address - Country:US
Practice Address - Phone:760-245-8828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-18
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA303032225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty