Healthcare Provider Details

I. General information

NPI: 1568064012
Provider Name (Legal Business Name): LISA NGO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2020
Last Update Date: 08/04/2021
Certification Date: 07/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6801 PARK TER FL DRIVE2
LOS ANGELES CA
90045-1543
US

IV. Provider business mailing address

11110 ALONDRA BLVD
NORWALK CA
90650-6203
US

V. Phone/Fax

Practice location:
  • Phone: 310-665-7100
  • Fax: 310-665-7101
Mailing address:
  • Phone: 626-872-4169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number50818
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: