Individual
EDSEL ICMAT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
10063 WINKLE CIR, ELK GROVE, CA 95757-6275
(510) 387-5178
Mailing address
10063 WINKLE CIR, ELK GROVE, CA 95757-6275
(510) 387-5178
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
8565
CA
Other
Enumeration date
05/14/2025
Last updated
05/14/2025
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