Provider Demographics
NPI:1841795150
Name:TABARES, JESUS ENRIQUE (CMT)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:ENRIQUE
Last Name:TABARES
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4423 LOREN ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90063-3223
Mailing Address - Country:US
Mailing Address - Phone:323-407-5491
Mailing Address - Fax:
Practice Address - Street 1:2333 BEVERLY BLVD STE 402-6
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2230
Practice Address - Country:US
Practice Address - Phone:323-407-5491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75025225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty