Provider Demographics
NPI:1598762452
Name:AMBRO, JOY DIRHAM (RPT)
Entity Type:Individual
Prefix:
First Name:JOY
Middle Name:DIRHAM
Last Name:AMBRO
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23109 FALENA AVE
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501-5618
Mailing Address - Country:US
Mailing Address - Phone:310-373-6226
Mailing Address - Fax:310-373-6557
Practice Address - Street 1:24026 VISTA MONTANA
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-6462
Practice Address - Country:US
Practice Address - Phone:310-373-6226
Practice Address - Fax:310-373-6557
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT14298208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT142980OtherBLUE SHIELD PROVIDER #
CAPT14298OtherSTATE LICENSE NUMBER