Basic Information
| Provider Information | |||||||||
| NPI: | 1548341258 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUTJONGDRO | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | ELGA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3250 LOMITA BLVD | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905055014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105398800 | ||||||||
| FaxNumber: | 3106985414 | ||||||||
| Practice Location | |||||||||
| Address1: | 824 E CARSON ST | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | CARSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907452262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105398800 | ||||||||
| FaxNumber: | 3106985414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 21685 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.