Provider Demographics
NPI:1871015651
Name:FACUNDO, MICEL
Entity Type:Individual
Prefix:MRS
First Name:MICEL
Middle Name:
Last Name:FACUNDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3116 MORNINGSIDE DR
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-4401
Mailing Address - Country:US
Mailing Address - Phone:562-506-7756
Mailing Address - Fax:
Practice Address - Street 1:3116 MORNINGSIDE DR
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4401
Practice Address - Country:US
Practice Address - Phone:562-506-7756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-12
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28310225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist