Provider Demographics
NPI:1336249978
Name:KREISWIRTH, ETHAN M (MA, ATC)
Entity type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:M
Last Name:KREISWIRTH
Suffix:
Gender:M
Credentials:MA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5361 W 126TH ST
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-4128
Mailing Address - Country:US
Mailing Address - Phone:310-243-3894
Mailing Address - Fax:
Practice Address - Street 1:CAL STATE DOMINGUEZ HLS
Practice Address - Street 2:1000 E. VICTORIA ST.
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90747-0001
Practice Address - Country:US
Practice Address - Phone:310-243-3894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist