Healthcare Provider Details

I. General information

NPI: 1760762744
Provider Name (Legal Business Name): UCLA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2011
Last Update Date: 08/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 WESTWOOD PLZ FL 4
LOS ANGELES CA
90095-0001
US

IV. Provider business mailing address

1000 VETERAN AVE STE A-744
LOS ANGELES CA
90024-2704
US

V. Phone/Fax

Practice location:
  • Phone: 310-794-4923
  • Fax:
Mailing address:
  • Phone: 310-825-6376
  • Fax: 310-794-1457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number27548
License Number StateCA

VIII. Authorized Official

Name: MS. ELAINE S. WONG
Title or Position: PHYSICAL THERAPIST
Credential: PT, MPT
Phone: 310-794-4923