Healthcare Provider Details

I. General information

NPI: 1164051397
Provider Name (Legal Business Name): MARC-OLIVIER ROGER FOGLIA PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2020
Last Update Date: 04/08/2020
Certification Date: 04/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 FOUNTAIN AVE
LOS ANGELES CA
90029-1006
US

IV. Provider business mailing address

3502 JASMINE AVE APT 204
LOS ANGELES CA
90034-4914
US

V. Phone/Fax

Practice location:
  • Phone: 323-465-2106
  • Fax:
Mailing address:
  • Phone: 310-926-6798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA48690
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: