Provider Demographics
NPI:1215208574
Name:AMAKU, ETE-KAMBA JEREMIAH (MS, ATC)
Entity Type:Individual
Prefix:
First Name:ETE-KAMBA
Middle Name:JEREMIAH
Last Name:AMAKU
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 RALSTON AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:BELMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94002-2869
Mailing Address - Country:US
Mailing Address - Phone:650-363-5668
Mailing Address - Fax:650-363-5669
Practice Address - Street 1:540 RALSTON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-2869
Practice Address - Country:US
Practice Address - Phone:650-363-5668
Practice Address - Fax:650-363-5669
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-19
Last Update Date:2012-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1279462255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer