Basic Information
| Provider Information | |||||||||
| NPI: | 1669139093 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARCIA | ||||||||
| FirstName: | IVET | ||||||||
| MiddleName: | GUADALUPE | ||||||||
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| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3848 TWEEDY BLVD STE B2, PO BOX 364 | ||||||||
| Address2: | |||||||||
| City: | SOUTH GATE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90280 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 AVIATION BLVD | ||||||||
| Address2: | |||||||||
| City: | REDONDO BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902784064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103762468 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2021 | ||||||||
| LastUpdateDate: | 11/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | CA | Y |
No ID Information.