Provider Demographics
NPI:1114398815
Name:TEJADA, SERGIO GERARDO (PTA)
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:GERARDO
Last Name:TEJADA
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 1:2267 DRUMMOND ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-1533
Mailing Address - Country:US
Mailing Address - Phone:951-236-5356
Mailing Address - Fax:
Practice Address - Street 1:2267 DRUMMOND ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-1533
Practice Address - Country:US
Practice Address - Phone:951-236-5356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10036225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant