Healthcare Provider Details

I. General information

NPI: 1003469149
Provider Name (Legal Business Name): BRIAN WOHLGEMUTH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2019
Last Update Date: 07/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2929 WAVERLY DR APT 318
LOS ANGELES CA
90039-4111
US

IV. Provider business mailing address

2929 WAVERLY DR APT 318
LOS ANGELES CA
90039-4111
US

V. Phone/Fax

Practice location:
  • Phone: 323-986-9999
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA-1149
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: