Provider Demographics
NPI:1780040048
Name:GURDIAN, ROGER
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:GURDIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22771 VIA SANTIAGO
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-2129
Mailing Address - Country:US
Mailing Address - Phone:310-803-3283
Mailing Address - Fax:
Practice Address - Street 1:25431 CABOT RD STE 207
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-5527
Practice Address - Country:US
Practice Address - Phone:310-803-3283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-01
Last Update Date:2016-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53121225700000X
FLMA 64186225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist