Healthcare Provider Details

I. General information

NPI: 1366120743
Provider Name (Legal Business Name): TUPOU T LEGER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TUPOU T ULUFONUA

II. Dates (important events)

Enumeration Date: 07/06/2023
Last Update Date: 04/17/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8525 S BROADWAY
LOS ANGELES CA
90003-3334
US

IV. Provider business mailing address

1618 ALVIRA ST
LOS ANGELES CA
90035-4518
US

V. Phone/Fax

Practice location:
  • Phone: 310-248-0240
  • Fax:
Mailing address:
  • Phone: 310-248-0240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: