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General NPI Number Information
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NPI Number | 1275288532
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Entity Type | Individual
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Provider Name | KEITH DIVINAGRACIA PT
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Gender | Male
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Dates
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Enumeration Date | 02/15/2022
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Last Update Date | 02/15/2022
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Provider Practice Location Address
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Address Line | 2051 N HIGHLAND AVE
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City | LOS ANGELES
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State | CA
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Zip | 90068-1373
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Country | US
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Telephone | 323-365-5458
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Fax |
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Provider Business Mailing Address
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Address Line | 560 CALLE ESTRELLA
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City | MONTEBELLO
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State | CA
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Zip | 90640-5533
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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 |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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