Healthcare Provider Details

I. General information

NPI: 1912822883
Provider Name (Legal Business Name): IRVIN BENEDICT ROTOL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41801 MONTANA DR
PALMDALE CA
93551-7513
US

IV. Provider business mailing address

41801 MONTANA DR
PALMDALE CA
93551-7513
US

V. Phone/Fax

Practice location:
  • Phone: 662-839-8276
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number55070
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: