Provider Demographics
NPI:1033528278
Name:CAJUCOM, WENCE (PTA)
Entity Type:Individual
Prefix:
First Name:WENCE
Middle Name:
Last Name:CAJUCOM
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 1:821 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94607-4422
Mailing Address - Country:US
Mailing Address - Phone:510-268-0222
Mailing Address - Fax:510-268-0111
Practice Address - Street 1:821 HARRISON ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-4422
Practice Address - Country:US
Practice Address - Phone:510-268-0222
Practice Address - Fax:510-268-0111
Is Sole Proprietor?:No
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10231225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10231OtherPHYSICAL THERAPY BOARD OF CALIFORNIA