Healthcare Provider Details

I. General information

NPI: 1073931473
Provider Name (Legal Business Name): JIMMY TOVAR B.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 04/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 W 6TH ST
LOS ANGELES CA
90017-1800
US

IV. Provider business mailing address

1111 W 6TH ST
LOS ANGELES CA
90017-1800
US

V. Phone/Fax

Practice location:
  • Phone: 323-404-1024
  • Fax:
Mailing address:
  • Phone: 323-404-1024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSPA2590
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: