Provider Demographics
NPI:1740696459
Name:OLIVER, ALLEN (PTA)
Entity type:Individual
Prefix:
First Name:ALLEN
Middle Name:
Last Name:OLIVER
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 1:4318 SPYRES WAY
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356
Mailing Address - Country:US
Mailing Address - Phone:209-576-0710
Mailing Address - Fax:209-576-0913
Practice Address - Street 1:1335 COFFEE RD #200
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355
Practice Address - Country:US
Practice Address - Phone:209-576-1946
Practice Address - Fax:209-576-0072
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT6373225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant