Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225400000X | Rehabilitation Practitioner |
NPI | 1023449758 |
---|---|
Provider Name | Jonathan Roman |
First Address | El Monte, CA 91731-3501 |
Second Address | West Covina, CA 91790-2138 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/12/2013 |
Last Update Date | 05/12/2013 |