Healthcare Provider Details

I. General information

NPI: 1306169735
Provider Name (Legal Business Name): ANDY GARRY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2010
Last Update Date: 03/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1517 W GARVEY AVE N
WEST COVINA CA
91790-2138
US

IV. Provider business mailing address

16263 SIERRA RIDGE WAY
HACIENDA HEIGHTS CA
91745-5547
US

V. Phone/Fax

Practice location:
  • Phone: 626-962-6061
  • Fax:
Mailing address:
  • Phone: 909-702-4544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT34716
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: