Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225400000X | Rehabilitation Practitioner |
NPI | 1023548294 |
---|---|
Provider Name | Mario Perez |
First Address | Los Angeles, CA 90007-4203 |
Second Address | Los Angeles, CA 90007-4203 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/06/2017 |
Last Update Date | 15/10/2019 |