Provider Demographics
NPI:1871999383
Name:KADOLPH, MICHAEL ROBERT (PTA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROBERT
Last Name:KADOLPH
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 1:16311 E ORANGE HILL CT
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91744-2349
Mailing Address - Country:US
Mailing Address - Phone:626-264-3600
Mailing Address - Fax:
Practice Address - Street 1:16311 E ORANGE HILL CT
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91744-2349
Practice Address - Country:US
Practice Address - Phone:626-264-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-11
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10590225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant