Provider Demographics
NPI:1205398989
Name:KISHORE, SHAMIT
Entity Type:Individual
Prefix:
First Name:SHAMIT
Middle Name:
Last Name:KISHORE
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 1:17729 ALMOND ORCHARD WAY
Mailing Address - Street 2:
Mailing Address - City:LATHROP
Mailing Address - State:CA
Mailing Address - Zip Code:95330-9375
Mailing Address - Country:US
Mailing Address - Phone:209-679-6943
Mailing Address - Fax:
Practice Address - Street 1:8801 FOLSOM BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-3257
Practice Address - Country:US
Practice Address - Phone:916-382-4447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician