Provider Demographics
NPI:1629438742
Name:TIENDA, JOSE (MS,ATC,CES)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:TIENDA
Suffix:
Gender:M
Credentials:MS,ATC,CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 W WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95203-1834
Mailing Address - Country:US
Mailing Address - Phone:209-639-1408
Mailing Address - Fax:
Practice Address - Street 1:530 W WILLOW ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95203-1834
Practice Address - Country:US
Practice Address - Phone:209-639-1408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer