Provider Demographics
NPI:1598379869
Name:BOSCH, FERNANDO REY DUPA
Entity Type:Individual
Prefix:
First Name:FERNANDO REY
Middle Name:DUPA
Last Name:BOSCH
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 1:7016 CORVUS CIR
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-8765
Mailing Address - Country:US
Mailing Address - Phone:916-518-6300
Mailing Address - Fax:
Practice Address - Street 1:7016 CORVUS CIR
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-8765
Practice Address - Country:US
Practice Address - Phone:916-518-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTA10893225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty