Provider Demographics
NPI:1376211706
Name:FULACHE, JERICHO
Entity Type:Individual
Prefix:
First Name:JERICHO
Middle Name:
Last Name:FULACHE
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 1:3208 HACIENDA DR
Mailing Address - Street 2:
Mailing Address - City:DUARTE
Mailing Address - State:CA
Mailing Address - Zip Code:91010-2313
Mailing Address - Country:US
Mailing Address - Phone:626-298-1328
Mailing Address - Fax:
Practice Address - Street 1:5522 GRACEWOOD AVE
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-8409
Practice Address - Country:US
Practice Address - Phone:626-579-0310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300829225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist