Provider Demographics
NPI:1194045302
Name:MANTOS LIM, VIRGENIA (PT)
Entity Type:Individual
Prefix:
First Name:VIRGENIA
Middle Name:
Last Name:MANTOS LIM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:VIRGENIA
Other - Middle Name:MONTERDE
Other - Last Name:MANTOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:8885 VENICE BLVD
Mailing Address - Street 2:#105
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-3242
Mailing Address - Country:US
Mailing Address - Phone:310-838-1552
Mailing Address - Fax:310-838-1553
Practice Address - Street 1:8885 VENICE BLVD
Practice Address - Street 2:#105
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-3242
Practice Address - Country:US
Practice Address - Phone:310-838-1552
Practice Address - Fax:310-838-1553
Is Sole Proprietor?:No
Enumeration Date:2010-06-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34685225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist