Provider Demographics
NPI:1003408410
Name:HERNAL, ROBERTO
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:
Last Name:HERNAL
Suffix:
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 1:9446 RALPH ST
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-2111
Mailing Address - Country:US
Mailing Address - Phone:323-344-2337
Mailing Address - Fax:
Practice Address - Street 1:3756 W AVENUE 40 STE 2B
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90065-3667
Practice Address - Country:US
Practice Address - Phone:323-344-2337
Practice Address - Fax:323-739-0094
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-07
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77079225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist