Healthcare Provider Details

I. General information

NPI: 1255016861
Provider Name (Legal Business Name): MIGUEL ANTONIO ULLOA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2023
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 W SIERRA MADRE BLVD
SIERRA MADRE CA
91024-2355
US

IV. Provider business mailing address

830 S CORAL TREE DR
WEST COVINA CA
91791-3327
US

V. Phone/Fax

Practice location:
  • Phone: 626-314-7862
  • Fax:
Mailing address:
  • Phone: 626-991-0122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: