Provider Demographics
NPI:1164737193
Name:SALVADOR, ATHENS RANDOLF ALCONCEL (PT)
Entity Type:Individual
Prefix:
First Name:ATHENS RANDOLF
Middle Name:ALCONCEL
Last Name:SALVADOR
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2705 TEMESCAL DR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-8612
Mailing Address - Country:US
Mailing Address - Phone:209-549-6365
Mailing Address - Fax:
Practice Address - Street 1:2705 TEMESCAL DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-8612
Practice Address - Country:US
Practice Address - Phone:209-549-6365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-14
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34599225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist