Healthcare Provider Details

I. General information

NPI: 1396225322
Provider Name (Legal Business Name): JUSTINN FRANK WADDELL RCP, RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2018
Last Update Date: 08/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13651 WILLARD ST
PANORAMA CITY CA
91402
US

IV. Provider business mailing address

10844 OXNARD ST APT 17
NORTH HOLLYWOOD CA
91606-5043
US

V. Phone/Fax

Practice location:
  • Phone: 818-815-2901
  • Fax:
Mailing address:
  • Phone: 818-605-9078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number33912
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: