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NPI Code Detail

MEDICARE: SUSAN MAIS-REQUEJO D.P.T.

MEDICARE: SUSAN MAIS-REQUEJO D.P.T.
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 TherapistPT18717CA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1PT181717OTHERCALICENSE

General Provider Information

NPI Number : 1730383506
Entity Type Code : Individual
Provider Name (Legal Business Name) : SUSAN MAIS-REQUEJO D.P.T.
Provider Business Mailing Address
First Line : 2819 JOSIE AVE
Second Line :
City : LONG BEACH
State : CA
Zip : 90815-1515
Country : US
Telephone Number : 562-743-3761
Fax Number : 596-496-3628
Provider Business Practice Location Address
First Line : 2819 JOSIE AVE
Second Line :
City : LONG BEACH
State : CA
Zip : 90815-1515
Country : US
Telephone Number : 562-743-3761
Fax Number : 596-496-3628
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/13/2007
Last Update Date : 04/30/2014

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