1669724225 NPI number — MR. BRIAN MYCHAL ENRIQUEZ M.S., ATC

Table of content: MR. BRIAN MYCHAL ENRIQUEZ M.S., ATC (NPI 1669724225)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669724225 NPI number — MR. BRIAN MYCHAL ENRIQUEZ M.S., ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ENRIQUEZ
Provider First Name:
BRIAN
Provider Middle Name:
MYCHAL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.S., ATC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669724225
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21817 FIGUEROA ST
Provider Second Line Business Mailing Address:
UNIT 12
Provider Business Mailing Address City Name:
CARSON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90745-1919
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-735-5238
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21817 FIGUEROA ST
Provider Second Line Business Practice Location Address:
UNIT 12
Provider Business Practice Location Address City Name:
CARSON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90745-1919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-735-5238
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/08/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  2000009460 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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