Healthcare Provider Details

I. General information

NPI: 1689762585
Provider Name (Legal Business Name): HADJI ALEJANDRO DEDACE P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1624 W OLIVE AVE STE E
BURBANK CA
91506-2459
US

IV. Provider business mailing address

1624 W. OLIVE SUITE E
BURBANK CA
91506
US

V. Phone/Fax

Practice location:
  • Phone: 818-846-1441
  • Fax: 818-846-1419
Mailing address:
  • Phone: 818-846-1441
  • Fax: 818-846-1419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberPT32175
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: