Provider Demographics
NPI:1174640031
Name:YOSUICO, TOM LACSON (PT)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:LACSON
Last Name:YOSUICO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:THOMAS
Other - Middle Name:LACSON
Other - Last Name:YOSUICO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:7415 BELLINGHAM AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91605-3676
Mailing Address - Country:US
Mailing Address - Phone:818-415-0149
Mailing Address - Fax:
Practice Address - Street 1:7415 BELLINGHAM AVE
Practice Address - Street 2:
Practice Address - City:N HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91605-3676
Practice Address - Country:US
Practice Address - Phone:818-415-0149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-24
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16161225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB233674Medicare PIN
CAAV316YMedicare PIN