Healthcare Provider Details

I. General information

NPI: 1083769707
Provider Name (Legal Business Name): WALT JAY MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 W WHITTIER BLVD
MONTEBELLO CA
90640-4004
US

IV. Provider business mailing address

PO BOX 39152
DOWNEY CA
90239-0152
US

V. Phone/Fax

Practice location:
  • Phone: 323-887-3577
  • Fax: 323-887-9567
Mailing address:
  • Phone: 310-724-0597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberDC16212
License Number StateCA

VIII. Authorized Official

Name: MRS. SHERINE GANEGODA
Title or Position: OFFICE MANAGER'S ASSISTANT
Credential:
Phone: 213-483-9902