Healthcare Provider Details

I. General information

NPI: 1457070070
Provider Name (Legal Business Name): LIVAN VALDIVIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2022
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1149 W 190TH ST STE 2200
GARDENA CA
90248-4344
US

IV. Provider business mailing address

177 E COLORADO BLVD STE 2082
PASADENA CA
91105-1986
US

V. Phone/Fax

Practice location:
  • Phone: 310-856-0800
  • Fax: 855-568-2494
Mailing address:
  • Phone: 844-669-7827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: