Healthcare Provider Details

I. General information

NPI: 1114018504
Provider Name (Legal Business Name): NEIL EDWARD VILLANUEVA P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

642 E WALNUT ST
PASADENA CA
91101-1612
US

IV. Provider business mailing address

642 E WALNUT ST
PASADENA CA
91101-1612
US

V. Phone/Fax

Practice location:
  • Phone: 310-351-2809
  • Fax:
Mailing address:
  • Phone: 310-351-2809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number29456
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: