Provider Demographics
NPI:1841742236
Name:CANDELARIA, KEITH A (MS, ATC)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:A
Last Name:CANDELARIA
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9253 MYRON ST
Mailing Address - Street 2:
Mailing Address - City:PICO RIVERA
Mailing Address - State:CA
Mailing Address - Zip Code:90660-5246
Mailing Address - Country:US
Mailing Address - Phone:562-544-1202
Mailing Address - Fax:
Practice Address - Street 1:13847 EARLHAM DR
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90602-6669
Practice Address - Country:US
Practice Address - Phone:562-907-4965
Practice Address - Fax:562-945-8024
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-01
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20000071692255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer