Active NPI
Theddy Trece Geronimo Grumo, PTA
- Physical Therapy Assistant
- Fresno, CA
National Provider Identifier
1104452267
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapy Assistant
- License
- 50168
- Practice address
- 5555 N Fresno St
Fresno, CA 93710-6006 - Phone
- (559) 430-8211
- NPI assigned
- Mar 19, 2020
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapy Assistant | 225200000X | 50168 | CA | Primary |
Addresses
Primary practice location
5555 N Fresno St
Fresno, CA 93710-6006
Mailing address
4560 SE International Way Ste 100
Milwaukie, OR 97222-4628
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 50168 | CA | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1584576000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1584576000000",
"number": "1104452267",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4560 SE INTERNATIONAL WAY STE 100",
"city": "MILWAUKIE",
"state": "OR",
"postal_code": "972224628"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "5555 N FRESNO ST",
"city": "FRESNO",
"state": "CA",
"postal_code": "937106006",
"telephone_number": "559-430-8211"
}
],
"practiceLocations": [],
"basic": {
"last_name": "GRUMO",
"first_name": "THEDDY TRECE",
"middle_name": "GERONIMO",
"name_prefix": "Mr.",
"credential": "PTA",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2020-03-19",
"last_updated": "2020-03-19",
"certification_date": "2020-03-19",
"status": "A"
},
"taxonomies": [
{
"code": "225200000X",
"taxonomy_group": "",
"desc": "Physical Therapy Assistant",
"state": "CA",
"license": "50168",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Fresno, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 19, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.