Healthcare Provider Details

I. General information

NPI: 1740212356
Provider Name (Legal Business Name): AILENE BUNDALIAN RIVERA RPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 01/12/2020
Certification Date: 01/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 W TEMPLE ST # 2056
LOS ANGELES CA
90026-5421
US

IV. Provider business mailing address

11024 BALBOA BLVD 504
GRANADA HILLS CA
91344-5007
US

V. Phone/Fax

Practice location:
  • Phone: 818-634-6328
  • Fax:
Mailing address:
  • Phone: 818-634-6328
  • Fax: 818-785-9332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License NumberPT28631
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: