Healthcare Provider Details

I. General information

NPI: 1306235379
Provider Name (Legal Business Name): MYLA GO PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2015
Last Update Date: 01/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4585 N FIGUEROA ST
LOS ANGELES CA
90065-3026
US

IV. Provider business mailing address

2828 MANHATTAN AVE
LA CRESCENTA CA
91214-3831
US

V. Phone/Fax

Practice location:
  • Phone: 323-223-3441
  • Fax:
Mailing address:
  • Phone: 818-572-5447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number9697
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: