Provider Demographics
NPI:1790229391
Name:KOLLI, SRIKANTH
Entity Type:Individual
Prefix:
First Name:SRIKANTH
Middle Name:
Last Name:KOLLI
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 1:4941 OLIVEHURST AVE
Mailing Address - Street 2:
Mailing Address - City:OLIVEHURST
Mailing Address - State:CA
Mailing Address - Zip Code:95961-4225
Mailing Address - Country:US
Mailing Address - Phone:530-743-4611
Mailing Address - Fax:
Practice Address - Street 1:4941 OLIVEHURST AVE
Practice Address - Street 2:
Practice Address - City:OLIVEHURST
Practice Address - State:CA
Practice Address - Zip Code:95961-4225
Practice Address - Country:US
Practice Address - Phone:530-743-4611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-15
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33448111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor