Healthcare Provider Details

I. General information

NPI: 1245720358
Provider Name (Legal Business Name): ALEXIS MICLAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2018
Last Update Date: 05/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18856 AMAR RD STE 8
WALNUT CA
91789-7102
US

IV. Provider business mailing address

1151 N NEW HAMPSHIRE AVE
LOS ANGELES CA
90029-1707
US

V. Phone/Fax

Practice location:
  • Phone: 626-667-8600
  • Fax:
Mailing address:
  • Phone: 213-298-6806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number49306
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: