Provider Demographics
NPI:1245692268
Name:MYLO MAGTOTO
Entity type:Organization
Organization Name:MYLO MAGTOTO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MYLO
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGTOTO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:510-459-9434
Mailing Address - Street 1:1080 CAROL LN
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-4756
Mailing Address - Country:US
Mailing Address - Phone:510-459-9434
Mailing Address - Fax:
Practice Address - Street 1:1080 CAROL LN
Practice Address - Street 2:SUITE 100
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-4756
Practice Address - Country:US
Practice Address - Phone:510-459-9434
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-28
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28260111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0282600Medicare PIN