Healthcare Provider Details

I. General information

NPI: 1770788978
Provider Name (Legal Business Name): MORGAN LYMAN FONES DPT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 01/03/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 MARENGO ST HRA 102
LOS ANGELES CA
90033-1036
US

IV. Provider business mailing address

1640 MARENGO ST HRA 102
LOS ANGELES CA
90033-1036
US

V. Phone/Fax

Practice location:
  • Phone: 323-224-7070
  • Fax: 323-224-7075
Mailing address:
  • Phone: 323-224-7070
  • Fax: 323-224-7075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number060402704
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT32946
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: