Healthcare Provider Details

I. General information

NPI: 1992682306
Provider Name (Legal Business Name): CAROLINA VILLAGOMEZ
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2025
Last Update Date: 08/18/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 S PROSPECTORS RD STE I
DIAMOND BAR CA
91765-1618
US

IV. Provider business mailing address

2129 CRYSTAL PL
POMONA CA
91767
US

V. Phone/Fax

Practice location:
  • Phone: 909-922-2497
  • Fax:
Mailing address:
  • Phone: 909-929-9243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number49893
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: