Provider Demographics
NPI:1487433058
Name:MALDONADO, EMMANUEL ELI (CMT)
Entity type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:ELI
Last Name:MALDONADO
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20107 LIVORNO WAY
Mailing Address - Street 2:
Mailing Address - City:PORTER RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:91326-4090
Mailing Address - Country:US
Mailing Address - Phone:818-371-4997
Mailing Address - Fax:
Practice Address - Street 1:11461 W WASHINGTON BLVD STE 1
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-6026
Practice Address - Country:US
Practice Address - Phone:424-543-4336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52278225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist