Provider Demographics
NPI:1992740658
Name:KUROSE, SHELLEY
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:KUROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 HARBOR BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691-3826
Mailing Address - Country:US
Mailing Address - Phone:916-375-1667
Mailing Address - Fax:916-375-1618
Practice Address - Street 1:11335A FOLSOM BLVD
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95742-6224
Practice Address - Country:US
Practice Address - Phone:916-858-0950
Practice Address - Fax:916-858-0972
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT285912251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT285910Medicare ID - Type UnspecifiedMEDICARE NUMBER