Healthcare Provider Details

I. General information

NPI: 1366366338
Provider Name (Legal Business Name): CANDICE REBECCA SHADGOO DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11611 SAN VICENTE BLVD STE L1
LOS ANGELES CA
90049-6534
US

IV. Provider business mailing address

11907 CHAPARAL ST
LOS ANGELES CA
90049-2909
US

V. Phone/Fax

Practice location:
  • Phone: 310-820-0013
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT296925
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: