Provider Demographics
NPI:1306910039
Name:MALO, DINA A (RPT)
Entity type:Individual
Prefix:
First Name:DINA
Middle Name:A
Last Name:MALO
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2517 SPRECKELS LN
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-5336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23133 HAWTHORNE BLVD
Practice Address - Street 2:#104
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-3729
Practice Address - Country:US
Practice Address - Phone:310-378-3456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT19593225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT19593OtherPHYSICAL THERAPY LICENSE
CABN156ZMedicare PIN