Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251G0304X | Physical Therapist - Geriatrics | PT17065 | CA |
NPI | 1295946846 |
---|---|
Provider Name | Kevin Laconta |
First Address | Burbank, CA 91504-1227 |
Second Address | Burbank, CA 91504-1227 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/05/2007 |
Last Update Date | 04/11/2010 |