Provider Demographics
NPI:1134952435
Name:ZELLMER, DEREK
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:ZELLMER
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 1:8200 HAVEN AVE APT 8107
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-6973
Mailing Address - Country:US
Mailing Address - Phone:608-343-9359
Mailing Address - Fax:
Practice Address - Street 1:2243 N MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-1586
Practice Address - Country:US
Practice Address - Phone:608-343-9359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-22
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner