Provider Demographics
NPI:1275096547
Name:CACANINDIN, KAREN KAYE MARTINEZ
Entity Type:Individual
Prefix:
First Name:KAREN KAYE
Middle Name:MARTINEZ
Last Name:CACANINDIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5501 NICHOLS DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2332
Mailing Address - Country:US
Mailing Address - Phone:562-810-8008
Mailing Address - Fax:
Practice Address - Street 1:5501 NICHOLS DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2332
Practice Address - Country:US
Practice Address - Phone:562-810-8008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-12
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.024072225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070.024072OtherILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION