Healthcare Provider Details

I. General information

NPI: 1760130140
Provider Name (Legal Business Name): EVER EDIZANDER GALLARDO PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2022
Last Update Date: 03/14/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18411 CLARK ST STE 302
TARZANA CA
91356-3541
US

IV. Provider business mailing address

8706 LEHIGH AVE
SUN VALLEY CA
91352-2742
US

V. Phone/Fax

Practice location:
  • Phone: 818-501-7276
  • Fax:
Mailing address:
  • Phone: 213-247-3274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number51571
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: