Healthcare Provider Details

I. General information

NPI: 1407415193
Provider Name (Legal Business Name): PHILIP JURY ALCEBAR LUNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2019
Last Update Date: 06/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 MISSION RD
GLENDALE CA
91205-3328
US

IV. Provider business mailing address

16005 S HARVARD BLVD APT A
GARDENA CA
90247-6153
US

V. Phone/Fax

Practice location:
  • Phone: 818-247-4476
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA49876
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: