Healthcare Provider Details

I. General information

NPI: 1962311811
Provider Name (Legal Business Name): ROGER VERMONT ZELAYA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1142 W UPLAND AVE
SAN PEDRO CA
90732-2652
US

IV. Provider business mailing address

1142 W UPLAND AVE
SAN PEDRO CA
90732-2652
US

V. Phone/Fax

Practice location:
  • Phone: 310-633-0749
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number311005
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: