Healthcare Provider Details

I. General information

NPI: 1295628352
Provider Name (Legal Business Name): ROGER IRA LOYOLA III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2025
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

289 W HUNTINGTON DR
ARCADIA CA
91007-3495
US

IV. Provider business mailing address

64 N OAK AVE UNIT 9
PASADENA CA
91107-5817
US

V. Phone/Fax

Practice location:
  • Phone: 626-396-8150
  • Fax:
Mailing address:
  • Phone: 818-388-9840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number51257
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: