Provider Demographics
NPI:1275702623
Name:ACEVEDO, MYNOR JEOVANY
Entity Type:Individual
Prefix:MR
First Name:MYNOR
Middle Name:JEOVANY
Last Name:ACEVEDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6677 DE LONGPRE AVENUE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028
Mailing Address - Country:US
Mailing Address - Phone:323-469-5786
Mailing Address - Fax:310-328-7217
Practice Address - Street 1:3751 STOCKER ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-5101
Practice Address - Country:US
Practice Address - Phone:323-290-5823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-29
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner