Provider Demographics
NPI:1376965392
Name:ENVERGA, KRIMSON ROMERO (PT)
Entity Type:Individual
Prefix:
First Name:KRIMSON
Middle Name:ROMERO
Last Name:ENVERGA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1226 N NORMANDIE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-1420
Mailing Address - Country:US
Mailing Address - Phone:323-304-1307
Mailing Address - Fax:
Practice Address - Street 1:1226 N NORMANDIE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-1420
Practice Address - Country:US
Practice Address - Phone:323-304-1307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-09
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40215225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist