Healthcare Provider Details

I. General information

NPI: 1790472041
Provider Name (Legal Business Name): ELIZABETH RAGUS PACOL GUM PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6080 CENTER DR. 6TH FLOOR SUITE #639
LOS ANGELES CA
90045-9004
US

IV. Provider business mailing address

6100 BUCKINGHAM PKWY UNIT 307
CULVER CITY CA
90230-7229
US

V. Phone/Fax

Practice location:
  • Phone: 888-859-0145
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number296949
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: