=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245720358
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEXIS MICLAT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2018
-----------------------------------------------------
Last Update Date | 05/14/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18856 AMAR RD STE 8
-----------------------------------------------------
City | WALNUT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91789-7102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-667-8600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1151 N NEW HAMPSHIRE AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90029-1707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-298-6806
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 49306
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------