Provider Demographics
NPI:1124795182
Name:TINOCO-MALACARA, JESUS (ATC, EMT)
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:TINOCO-MALACARA
Suffix:
Gender:M
Credentials:ATC, EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 E 61ST ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90805-2904
Mailing Address - Country:US
Mailing Address - Phone:562-331-8276
Mailing Address - Fax:
Practice Address - Street 1:406 E 61ST ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90805-2904
Practice Address - Country:US
Practice Address - Phone:562-331-8276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20000501152255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer