Provider Demographics
NPI:1588319420
Name:HALIBURTON, RONALD CHARLES JR
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:CHARLES
Last Name:HALIBURTON
Suffix:JR
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 1:8033 1/2 70TH ST
Mailing Address - Street 2:
Mailing Address - City:PARAMOUNT
Mailing Address - State:CA
Mailing Address - Zip Code:90723-5440
Mailing Address - Country:US
Mailing Address - Phone:562-341-8325
Mailing Address - Fax:
Practice Address - Street 1:8033 1/2 70TH ST
Practice Address - Street 2:
Practice Address - City:PARAMOUNT
Practice Address - State:CA
Practice Address - Zip Code:90723-5440
Practice Address - Country:US
Practice Address - Phone:562-341-8325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA88527225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist