Healthcare Provider Details

I. General information

NPI: 1457531980
Provider Name (Legal Business Name): GLORIA JULISSA MUNOZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2007
Last Update Date: 01/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 VINE ST
LOS ANGELES CA
90038-1612
US

IV. Provider business mailing address

5715 S BROADWAY
LOS ANGELES CA
90037-4131
US

V. Phone/Fax

Practice location:
  • Phone: 323-769-6100
  • Fax:
Mailing address:
  • Phone: 323-948-0444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: