Healthcare Provider Details

I. General information

NPI: 1063076180
Provider Name (Legal Business Name): TARA TOLOOEE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 04/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11710 WILSHIRE BLVD
LOS ANGELES CA
90025-1503
US

IV. Provider business mailing address

11710 WILSHIRE BLVD
LOS ANGELES CA
90025-1503
US

V. Phone/Fax

Practice location:
  • Phone: 310-494-1422
  • Fax: 310-496-0868
Mailing address:
  • Phone: 310-494-1422
  • Fax: 310-496-0868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number49916
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: