Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225400000X | Rehabilitation Practitioner |
NPI | 1023597788 |
---|---|
Provider Name | Miss Jessica Avila |
First Address | Reseda, CA 91335-6308 |
Second Address | Reseda, CA 91335-6308 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/08/2018 |
Last Update Date | 13/08/2018 |