Provider Demographics
NPI:1205269263
Name:CABRERA, KENNETH W (PTA)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:CABRERA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1634 CURTIS ST # B
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-1706
Mailing Address - Country:US
Mailing Address - Phone:760-791-5633
Mailing Address - Fax:
Practice Address - Street 1:1634 CURTIS ST # B
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-1706
Practice Address - Country:US
Practice Address - Phone:760-791-5633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-14
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT 6506225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant