Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225400000X | Rehabilitation Practitioner |
NPI | 1033667639 |
---|---|
Provider Name | Mia Deandra Carmona |
First Address | Brea, CA 92821-3417 |
Second Address | Cerritos, CA 90703-2640 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/09/2016 |
Last Update Date | 13/09/2016 |