Provider Demographics
NPI:1407995160
Name:POBLANO, ROBERT L JR
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:POBLANO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ROB
Other - Middle Name:L
Other - Last Name:POBLANO
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:123 PENDERGAST LN
Mailing Address - Street 2:
Mailing Address - City:OROVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95966-8299
Mailing Address - Country:US
Mailing Address - Phone:530-321-3971
Mailing Address - Fax:
Practice Address - Street 1:3100 ORO DAM BLVD E
Practice Address - Street 2:
Practice Address - City:OROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95966-5183
Practice Address - Country:US
Practice Address - Phone:530-534-4568
Practice Address - Fax:530-534-3657
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT21227225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT212270OtherLICENSE
CA0PT212270Medicare PIN