Healthcare Provider Details

I. General information

NPI: 1245994656
Provider Name (Legal Business Name): LUIS GARCIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2021
Last Update Date: 10/22/2021
Certification Date: 10/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 CARRILLO DR STE 103
LOS ANGELES CA
90048-5400
US

IV. Provider business mailing address

701 S GARFIELD AVE APT A
MONTEREY PARK CA
91754-3975
US

V. Phone/Fax

Practice location:
  • Phone: 310-854-0529
  • Fax:
Mailing address:
  • Phone: 626-789-4158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number51314
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: