Provider Demographics
NPI:1730633462
Name:PACHECO, ROBERT A (DPT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:PACHECO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100 PMB 700
Mailing Address - Street 2:
Mailing Address - City:MAMMOTH LAKES
Mailing Address - State:CA
Mailing Address - Zip Code:93546
Mailing Address - Country:US
Mailing Address - Phone:760-924-4148
Mailing Address - Fax:
Practice Address - Street 1:2701 W ALAMEDA AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4402
Practice Address - Country:US
Practice Address - Phone:818-841-3936
Practice Address - Fax:818-841-5974
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-11
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT291664208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation