Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225400000X | Rehabilitation Practitioner |
NPI | 1003163270 |
---|---|
Provider Name | Michael John Michaelides JR. |
First Address | Azusa, CA 91702-5582 |
Second Address | Azusa, CA 91702-5582 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/08/2012 |
Last Update Date | 07/03/2018 |