Provider Demographics
NPI:1053061762
Name:GERALDI, KEN
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:GERALDI
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 1:105 RUSH CREEK CT
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94582-5624
Mailing Address - Country:US
Mailing Address - Phone:408-628-8266
Mailing Address - Fax:
Practice Address - Street 1:1701 W CHARLESTON BLVD STE 230
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2312
Practice Address - Country:US
Practice Address - Phone:702-660-8658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2023-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program