Healthcare Provider Details

I. General information

NPI: 1518098607
Provider Name (Legal Business Name): RADICK ABOLUCION HERRERA JR. RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 11/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1549 W OLYMPIC BLVD
LOS ANGELES CA
90015-3806
US

IV. Provider business mailing address

8002 HOLT ST
BUENA PARK CA
90621-2132
US

V. Phone/Fax

Practice location:
  • Phone: 213-381-7479
  • Fax:
Mailing address:
  • Phone: 562-857-9301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number55327
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: