Provider Demographics
NPI:1114634110
Name:JIALAL, GANESH (PTA)
Entity Type:Individual
Prefix:MR
First Name:GANESH
Middle Name:
Last Name:JIALAL
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 1:70 PALATINE APT 408
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-7666
Mailing Address - Country:US
Mailing Address - Phone:530-400-4637
Mailing Address - Fax:
Practice Address - Street 1:1020 TERMINO AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-4123
Practice Address - Country:US
Practice Address - Phone:562-433-6791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant