=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932922622
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ABEL REYES LANDA JR. PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2024
-----------------------------------------------------
Last Update Date | 11/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12539 IMPERIAL HWY STE 201
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90650-3106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-379-9541
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14338 DISNEY AVE
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90650-5037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-712-0191
-----------------------------------------------------
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 | 53719
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------