Provider Demographics
NPI:1043020316
Name:JUAN, ANGELINA
Entity type:Individual
Prefix:
First Name:ANGELINA
Middle Name:
Last Name:JUAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4175 S ALAMEDA ST
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CA
Mailing Address - Zip Code:90058-1624
Mailing Address - Country:US
Mailing Address - Phone:323-283-2745
Mailing Address - Fax:
Practice Address - Street 1:4175 S ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CA
Practice Address - Zip Code:90058-1624
Practice Address - Country:US
Practice Address - Phone:323-283-2745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-09
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA91158225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist