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General NPI Number Information
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NPI Number | 1275085235
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Entity Type | Organization
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Legal Business Name | 123 PEDIATRIC THERAPY, A PHYSICAL THERAPY P.C.
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Dates
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Enumeration Date | 10/25/2016
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Last Update Date | 01/08/2019
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Provider Practice Location Address
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Address Line | 855 N LARK ELLEN AVE SUITE L
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City | WEST COVINA
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State | CA
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Zip | 91791-1099
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Country | US
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Telephone | 909-964-2186
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Fax |
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Provider Business Mailing Address
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Address Line | 926 W 12TH ST
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City | POMONA
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State | CA
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Zip | 91766-2835
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | KAREN APRIL HWANG
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Credential | MSPT
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Telephone | 909-964-2186
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State |
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