Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225400000X | Rehabilitation Practitioner |
NPI | 1013280932 |
---|---|
Provider Name | Mario Brian Flores |
First Address | La Verne, CA 91750 |
Second Address | La Verne, CA 91750-2353 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/02/2012 |
Last Update Date | 15/09/2014 |