Provider Demographics
NPI:1083354260
Name:VILLANUEVA, JAVIER (PTA)
Entity Type:Individual
Prefix:
First Name:JAVIER
Middle Name:
Last Name:VILLANUEVA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17628 ALBURTIS AVE UNIT 4
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:CA
Mailing Address - Zip Code:90701-3868
Mailing Address - Country:US
Mailing Address - Phone:562-391-6749
Mailing Address - Fax:
Practice Address - Street 1:17628 ALBURTIS AVE UNIT 4
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:CA
Practice Address - Zip Code:90701-3868
Practice Address - Country:US
Practice Address - Phone:562-391-6749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51244225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant