Provider Demographics
NPI:1619428174
Name:BANDOQUILLO, JICHELLE CATAQUIZ (RPT)
Entity Type:Individual
Prefix:
First Name:JICHELLE
Middle Name:CATAQUIZ
Last Name:BANDOQUILLO
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:JICHELLE
Other - Middle Name:BANDOQUILLO
Other - Last Name:ALVARADO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8366 DEERING AVE
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91304-2768
Mailing Address - Country:US
Mailing Address - Phone:562-293-8918
Mailing Address - Fax:
Practice Address - Street 1:10605 BALBOA BLVD
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-6342
Practice Address - Country:US
Practice Address - Phone:562-293-8918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-20
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30321225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist