Healthcare Provider Details

I. General information

NPI: 1619756558
Provider Name (Legal Business Name): TY HURTADO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2023
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 S FIGUEROA ST
LOS ANGELES CA
90015-1392
US

IV. Provider business mailing address

13428 MAXELLA AVE STE 913
MARINA DEL REY CA
90292-5620
US

V. Phone/Fax

Practice location:
  • Phone: 424-272-5238
  • Fax:
Mailing address:
  • Phone: 424-272-5238
  • 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: