Provider Demographics
NPI:1720161227
Name:MIRANDO, ROMMEL B (PT)
Entity type:Individual
Prefix:MR
First Name:ROMMEL
Middle Name:B
Last Name:MIRANDO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2937 MARY ST
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-3421
Mailing Address - Country:US
Mailing Address - Phone:347-393-7661
Mailing Address - Fax:
Practice Address - Street 1:2937 MARY ST
Practice Address - Street 2:
Practice Address - City:LA CRESCENTA
Practice Address - State:CA
Practice Address - Zip Code:91214-3421
Practice Address - Country:US
Practice Address - Phone:347-393-7661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024451-1225100000X
CA33677225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist