Healthcare Provider Details

I. General information

NPI: 1639780257
Provider Name (Legal Business Name): ERIK FERNANDO TRUJILLO PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2020
Last Update Date: 08/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11926 LA MIRADA BLVD
LA MIRADA CA
90638-1303
US

IV. Provider business mailing address

6809 GLENGARRY AVE
WHITTIER CA
90606-1628
US

V. Phone/Fax

Practice location:
  • Phone: 562-943-7156
  • Fax:
Mailing address:
  • Phone: 562-879-3745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number49218
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: