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General NPI Number Information
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NPI Number | 1285865832
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Entity Type | Individual
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Provider Name | STEVANUS IBRAHIM PT, D.P.T.
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Gender | Male
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Dates
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Enumeration Date | 07/30/2009
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Last Update Date | 06/14/2021
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Provider Practice Location Address
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Address Line | 1135 S SUNSET AVE STE 101
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City | WEST COVINA
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State | CA
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Zip | 91790-3938
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Country | US
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Telephone | 626-732-8351
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Fax | 626-732-8352
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Provider Business Mailing Address
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Address Line | 3013 E MESA DR
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City | WEST COVINA
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State | CA
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Zip | 91791-2227
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Country | US
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Telephone | 626-347-9722
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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 | 35401
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License Number State | CA
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