Healthcare Provider Details

I. General information

NPI: 1184940769
Provider Name (Legal Business Name): VON LLAVE OTR, CSST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2010
Last Update Date: 04/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1643 W PACIFIC COAST HWY #39
WILMINGTON CA
90744-1876
US

IV. Provider business mailing address

1643 WEST PACIFIC COAST HIGHWAY #39
WILMINGTON CA
90744
US

V. Phone/Fax

Practice location:
  • Phone: 310-803-7938
  • Fax:
Mailing address:
  • Phone: 310-803-7938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number9472
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: