Provider Demographics
NPI:1609319276
Name:MOMIN, RESHMABANU
Entity Type:Individual
Prefix:
First Name:RESHMABANU
Middle Name:
Last Name:MOMIN
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 1:2841 E LINCOLN AVE APT 231
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-4022
Mailing Address - Country:US
Mailing Address - Phone:619-200-6992
Mailing Address - Fax:
Practice Address - Street 1:215 N STATE COLLEGE BLVD STE G
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-2932
Practice Address - Country:US
Practice Address - Phone:714-999-6596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48361225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant