Provider Demographics
NPI:1972186039
Name:QUACH, JIMMY
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:QUACH
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 1:656 GREYCLIFF AVE
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91744-3103
Mailing Address - Country:US
Mailing Address - Phone:626-216-2816
Mailing Address - Fax:
Practice Address - Street 1:656 GREYCLIFF AVE
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91744-3103
Practice Address - Country:US
Practice Address - Phone:626-216-2816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-05
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT299935225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist