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NPI Code Detail

MEDICARE: JACQUELYN M DYLLA

MEDICARE: JACQUELYN M DYLLA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12251X0800XOrthopedic Physical TherapistPT19562CA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1PT19562OTHERCALICENSE

General Provider Information

NPI Number : 1649395997
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACQUELYN M DYLLA
Provider Business Mailing Address
First Line : 1640 MARENGO ST
Second Line : #102
City : LOS ANGELES
State : CA
Zip : 90033-1036
Country : US
Telephone Number : 213-821-2559
Fax Number : 213-821-1499
Provider Business Practice Location Address
First Line : 3301 S HOOVER AVE
Second Line :
City : LOS ANGELES
State : CA
Zip : 90089-0001
Country : US
Telephone Number : 213-740-0215
Fax Number : 213-821-1499
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/19/2007
Last Update Date : 07/08/2007

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Directions to “ JACQUELYN M DYLLA ” Practice Location

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