Provider Demographics
NPI:1689762585
Name:DEDACE, HADJI ALEJANDRO (PT)
Entity Type:Individual
Prefix:
First Name:HADJI
Middle Name:ALEJANDRO
Last Name:DEDACE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1624 W. OLIVE SUITE E
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91506
Mailing Address - Country:US
Mailing Address - Phone:818-846-1441
Mailing Address - Fax:818-846-1419
Practice Address - Street 1:1624 W OLIVE AVE STE E
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91506-2459
Practice Address - Country:US
Practice Address - Phone:818-846-1441
Practice Address - Fax:818-846-1419
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT321752081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT 32175OtherPHYSICAL THERAPY