Provider Demographics
NPI:1922856723
Name:TAMAYO, JUAN
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:TAMAYO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4847 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-3554
Mailing Address - Country:US
Mailing Address - Phone:310-251-9115
Mailing Address - Fax:
Practice Address - Street 1:5901 W CENTURY BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-5411
Practice Address - Country:US
Practice Address - Phone:310-215-6020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-08
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48330225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant