Healthcare Provider Details

I. General information

NPI: 1144640723
Provider Name (Legal Business Name): KENNETH GUSTAFSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2014
Last Update Date: 04/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23888 MULHOLLAND DRIVE MS # 270
WOODLAND HILLS CA
91364
US

IV. Provider business mailing address

5767 W CENTURY BLVD SUITE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 818-875-1050
  • Fax:
Mailing address:
  • Phone: 310-301-8714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberAT 4143
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: