Provider Demographics
NPI:1760130140
Name:GALLARDO, EVER EDIZANDER (PTA)
Entity Type:Individual
Prefix:
First Name:EVER
Middle Name:EDIZANDER
Last Name:GALLARDO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8706 LEHIGH AVE
Mailing Address - Street 2:
Mailing Address - City:SUN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91352-2742
Mailing Address - Country:US
Mailing Address - Phone:213-247-3274
Mailing Address - Fax:
Practice Address - Street 1:18411 CLARK ST STE 302
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3541
Practice Address - Country:US
Practice Address - Phone:818-501-7276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51571225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant