Provider Demographics
NPI:1932203387
Name:HALLBOURG, MARK A (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:HALLBOURG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:11930 HERITAGE OAK PL
Practice Address - Street 2:SUITE 9
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-2458
Practice Address - Country:US
Practice Address - Phone:530-887-8785
Practice Address - Fax:530-887-8112
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT10773225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0107730Medicaid
CAPT0107730Medicaid
R24494Medicare UPIN
CAOPT107733Medicare PIN