Provider Demographics
NPI:1982724951
Name:SITANGGANG, DELWYN GEORGE (MPT)
Entity Type:Individual
Prefix:MR
First Name:DELWYN
Middle Name:GEORGE
Last Name:SITANGGANG
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 MADISON RIVER DR
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-5182
Mailing Address - Country:US
Mailing Address - Phone:530-515-6890
Mailing Address - Fax:530-222-2774
Practice Address - Street 1:2700 MADISON RIVER DR
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-5182
Practice Address - Country:US
Practice Address - Phone:530-515-6890
Practice Address - Fax:530-222-2774
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25880225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT258801Medicare ID - Type Unspecified