MEDICARE: JUDE ANDREW CARBON

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
1	225200000X	Physical Therapy Assistant

General Provider Information

NPI Number	:	1811469612
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUDE ANDREW CARBON

Provider Business Mailing Address
First Line	:	5642 GENTRY AVE
Second Line	:
City	:	VALLEY VILLAGE
State	:	CA
Zip	:	91607-1817
Country	:	US
Telephone Number	:	818-618-8920
Fax Number	:

Provider Business Practice Location Address
First Line	:	2415 S WESTERN AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90018-2608
Country	:	US
Telephone Number	:	323-734-1101
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/18/2018
Last Update Date	:	12/18/2018

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Directions to “ JUDE ANDREW CARBON ” Practice Location

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