Healthcare Provider Details

I. General information

NPI: 1104940485
Provider Name (Legal Business Name): SONIA CHAGOLLA MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 04/26/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 WILSHIRE BLVD STE 300
LOS ANGELES CA
90017-1931
US

IV. Provider business mailing address

1200 WILSHIRE BLVD
LOS ANGELES CA
90017-1908
US

V. Phone/Fax

Practice location:
  • Phone: 213-481-7464
  • Fax:
Mailing address:
  • Phone: 213-481-7464
  • Fax: 213-481-7417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: