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NPI Code Detail

MEDICARE: TINA M ENWALL C.P.R.P.

MEDICARE: TINA M ENWALL C.P.R.P.
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
1171M00000XCase Manager/Care Coordinator
2225400000XRehabilitation Practitioner
3175T00000XPeer SpecialistMPSS-FHADQECA

General Provider Information

NPI Number : 1649420597
Entity Type Code : Individual
Provider Name (Legal Business Name) : TINA M ENWALL C.P.R.P.
Provider Business Mailing Address
First Line : 2677 ZOE AVE STE 304
Second Line :
City : HUNTINGTON PARK
State : CA
Zip : 90255-3699
Country : US
Telephone Number : 323-346-0960
Fax Number :
Provider Business Practice Location Address
First Line : 2677 ZOE AVE STE 304
Second Line :
City : HUNTINGTON PARK
State : CA
Zip : 90255-3699
Country : US
Telephone Number : 323-346-0960
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/29/2008
Last Update Date : 09/14/2023

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