Provider Demographics
NPI:1881204063
Name:GOLDBERG, ALYSSA (CPO)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:CPO
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:
Other - Last Name:GOLDBERG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CPO
Mailing Address - Street 1:2669 MYRTLE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:SIGNAL HILL
Mailing Address - State:CA
Mailing Address - Zip Code:90755-2746
Mailing Address - Country:US
Mailing Address - Phone:562-595-6445
Mailing Address - Fax:562-424-3122
Practice Address - Street 1:2669 MYRTLE AVE STE 101
Practice Address - Street 2:
Practice Address - City:SIGNAL HILL
Practice Address - State:CA
Practice Address - Zip Code:90755-2746
Practice Address - Country:US
Practice Address - Phone:562-595-6445
Practice Address - Fax:562-424-3122
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPO04821224P00000X
CACO006089222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGXC000190OtherMEDICAL