Provider Demographics
NPI:1417237587
Name:ALCANTARA, MARIO MIER (PT)
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:MIER
Last Name:ALCANTARA
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 1:5913 PEPPERWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712-1142
Mailing Address - Country:US
Mailing Address - Phone:562-804-1860
Mailing Address - Fax:
Practice Address - Street 1:3902 KATELLA AVE
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3304
Practice Address - Country:US
Practice Address - Phone:562-596-5561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-22
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26309225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist