Provider Demographics
NPI:1518534809
Name:ROMO, LUIS MIGUEL
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:MIGUEL
Last Name:ROMO
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 1:6022 VARIEL AVE
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-3719
Mailing Address - Country:US
Mailing Address - Phone:818-996-1056
Mailing Address - Fax:818-337-7156
Practice Address - Street 1:6022 VARIEL AVE
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-3719
Practice Address - Country:US
Practice Address - Phone:818-996-1056
Practice Address - Fax:818-337-7156
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA96000115261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty