Provider Demographics
NPI:1457556607
Name:BALELO, RICHARD GONSALVES JR (PT)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:GONSALVES
Last Name:BALELO
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:10894 KEMAH LN
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-1320
Mailing Address - Country:US
Mailing Address - Phone:858-271-4596
Mailing Address - Fax:
Practice Address - Street 1:400 CRAVEN RD
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-4201
Practice Address - Country:US
Practice Address - Phone:710-510-4032
Practice Address - Fax:710-510-5600
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 160752251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic