Healthcare Provider Details

I. General information

NPI: 1992125603
Provider Name (Legal Business Name): JONATHAN RICALDE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 04/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6762 LEXINGTON AVE SUITE A
LOS ANGELES CA
90038-1217
US

IV. Provider business mailing address

1328 2ND ST
SANTA MONICA CA
90401-1122
US

V. Phone/Fax

Practice location:
  • Phone: 323-380-7590
  • Fax: 323-380-7591
Mailing address:
  • Phone: 310-576-1308
  • Fax: 310-576-1027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: