Provider Demographics
NPI:1497324156
Name:ANTIMO, LIZETH
Entity Type:Individual
Prefix:
First Name:LIZETH
Middle Name:
Last Name:ANTIMO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1157 LEMOYNE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-3206
Mailing Address - Country:US
Mailing Address - Phone:213-483-6335
Mailing Address - Fax:
Practice Address - Street 1:3731 STOCKER ST
Practice Address - Street 2:
Practice Address - City:VIEW PARK
Practice Address - State:CA
Practice Address - Zip Code:90008-5118
Practice Address - Country:US
Practice Address - Phone:323-296-8446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner