Provider Demographics
NPI:1598896284
Name:MAGALLANES, GERARDO JR (BS)
Entity Type:Individual
Prefix:MR
First Name:GERARDO
Middle Name:
Last Name:MAGALLANES
Suffix:JR
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 S WINTON AVE
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91744-5735
Mailing Address - Country:US
Mailing Address - Phone:323-208-2767
Mailing Address - Fax:
Practice Address - Street 1:12021 WILMINGTON AVE LOT C
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-3019
Practice Address - Country:US
Practice Address - Phone:310-668-8260
Practice Address - Fax:310-668-8311
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner