Provider Demographics
NPI:1104015437
Name:MLEZIVA, PABLO (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:PABLO
Middle Name:
Last Name:MLEZIVA
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33410 WALLACE WAY
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-3488
Mailing Address - Country:US
Mailing Address - Phone:909-266-0821
Mailing Address - Fax:
Practice Address - Street 1:12139 MOUNT VERNON AVE STE 110
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5500
Practice Address - Country:US
Practice Address - Phone:909-370-3396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33597225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist