Provider Demographics
NPI:1376206839
Name:AGBAGALA, PATRICIO ANGELO
Entity Type:Individual
Prefix:
First Name:PATRICIO
Middle Name:ANGELO
Last Name:AGBAGALA
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 1:1600 MAIN ST FL 2
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-3626
Mailing Address - Country:US
Mailing Address - Phone:888-859-0145
Mailing Address - Fax:
Practice Address - Street 1:1600 MAIN ST FL 2
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-3626
Practice Address - Country:US
Practice Address - Phone:888-859-0145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist