Provider Demographics
NPI:1538268016
Name:KALK, EILEEN R (PA)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:R
Last Name:KALK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 PAGE DR
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-3419
Mailing Address - Country:US
Mailing Address - Phone:707-263-1855
Mailing Address - Fax:
Practice Address - Street 1:4135 MAIN ST
Practice Address - Street 2:
Practice Address - City:KELSEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95451-8941
Practice Address - Country:US
Practice Address - Phone:707-279-1888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17682363A00000X
CAPT10212225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA17682OtherPA LICENSE NUMBER