Healthcare Provider Details

I. General information

NPI: 1114393667
Provider Name (Legal Business Name): JESUS PANTOJA JR. PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2015
Last Update Date: 08/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11627 TELEGRAPH RD SUITE 105
SANTA FE SPRINGS CA
90670-3693
US

IV. Provider business mailing address

7424 KENGARD AVE
WHITTIER CA
90606-2437
US

V. Phone/Fax

Practice location:
  • Phone: 562-948-4004
  • Fax:
Mailing address:
  • Phone: 323-633-3971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberAT5738
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: