Provider Demographics
NPI:1437667474
Name:MAGALLANES, JEFF
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:MAGALLANES
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 1:255 W 7TH ST APT 18
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-0304
Mailing Address - Country:US
Mailing Address - Phone:714-331-6716
Mailing Address - Fax:
Practice Address - Street 1:12151 DALE AVE
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:CA
Practice Address - Zip Code:90680-3889
Practice Address - Country:US
Practice Address - Phone:714-530-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT17603225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist