Provider Demographics
NPI:1164959912
Name:VILLARRUEL, ANGELICA (OMT)
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:
Last Name:VILLARRUEL
Suffix:
Gender:F
Credentials:OMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 N RECORD AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90063
Mailing Address - Country:US
Mailing Address - Phone:323-268-2144
Mailing Address - Fax:323-544-1442
Practice Address - Street 1:303 N RECORD AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90063
Practice Address - Country:US
Practice Address - Phone:323-268-2144
Practice Address - Fax:323-544-1442
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72058225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist