Healthcare Provider Details

I. General information

NPI: 1477887321
Provider Name (Legal Business Name): MAILA TIBBERTS P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MAILA CASTRO ASISTIO P.T.

II. Dates (important events)

Enumeration Date: 09/24/2009
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12113 SANTA MONICA BLVD SUITE 203
LOS ANGELES CA
90025-2581
US

IV. Provider business mailing address

4640 CANEEL BAY CT
OCEANSIDE CA
92057-4223
US

V. Phone/Fax

Practice location:
  • Phone: 310-309-3721
  • Fax:
Mailing address:
  • Phone: 109-566-1053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number031126-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 36737
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: