Healthcare Provider Details

I. General information

NPI: 1730753591
Provider Name (Legal Business Name): MICHAEL T MAGTIRA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2021
Last Update Date: 05/17/2021
Certification Date: 05/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 E WASHINGTON BLVD STE 230
PASADENA CA
91107-1449
US

IV. Provider business mailing address

9241 BLACKLEY ST
TEMPLE CITY CA
91780-3137
US

V. Phone/Fax

Practice location:
  • Phone: 626-296-8900
  • Fax:
Mailing address:
  • Phone: 626-247-0574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number709861
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: