Provider Demographics
NPI:1134220700
Name:COSTALES, RONALD PILAR JR (PT)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:PILAR
Last Name:COSTALES
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2681 W OLYMPIC BLVD
Mailing Address - Street 2:SUITE 2201
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2810
Mailing Address - Country:US
Mailing Address - Phone:213-383-7030
Mailing Address - Fax:213-383-7031
Practice Address - Street 1:2681 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 2201
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2810
Practice Address - Country:US
Practice Address - Phone:213-383-7030
Practice Address - Fax:213-383-7031
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT29975225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT29975OtherLICENSE