Provider Demographics
NPI:1366116170
Name:AGRAVIADOR, BUENAVENTURA GAVIOLA III (PTLA)
Entity type:Individual
Prefix:
First Name:BUENAVENTURA
Middle Name:GAVIOLA
Last Name:AGRAVIADOR
Suffix:III
Gender:M
Credentials:PTLA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18709 FRANKFORT ST
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-4523
Mailing Address - Country:US
Mailing Address - Phone:818-358-9992
Mailing Address - Fax:
Practice Address - Street 1:18709 FRANKFORT ST
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324-4523
Practice Address - Country:US
Practice Address - Phone:818-358-9992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-04
Last Update Date:2023-08-04
Deactivation Date:2023-02-21
Deactivation Code:
Reactivation Date:2023-08-04
Provider Licenses
StateLicense IDTaxonomies
CAPTLA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist