Provider Demographics
NPI:1184758252
Name:LEGARRETA, EDWIN KENNETH
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:KENNETH
Last Name:LEGARRETA
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 1:20159 COHASSET ST
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:CA
Mailing Address - Zip Code:91306-2961
Mailing Address - Country:US
Mailing Address - Phone:818-267-4241
Mailing Address - Fax:
Practice Address - Street 1:6931 VAN NUYS BLVD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3937
Practice Address - Country:US
Practice Address - Phone:818-909-5870
Practice Address - Fax:818-909-9980
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner