Basic Information
| Provider Information | |||||||||
| NPI: | 1356895908 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACIAS | ||||||||
| FirstName: | GERARDO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 488 S SAN VICENTE BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900484107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236559055 | ||||||||
| FaxNumber: | 3236559255 | ||||||||
| Practice Location | |||||||||
| Address1: | 488 S SAN VICENTE BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900484107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236559055 | ||||||||
| FaxNumber: | 3236559255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2016 | ||||||||
| LastUpdateDate: | 08/30/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT 291812 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.