Provider Demographics
NPI:1265104806
Name:SIMENTAL, JORGE ANTONIO (MT)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:ANTONIO
Last Name:SIMENTAL
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 S EASTMAN AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90023-1942
Mailing Address - Country:US
Mailing Address - Phone:424-331-5661
Mailing Address - Fax:310-760-2033
Practice Address - Street 1:8725 LA TIJERA BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3906
Practice Address - Country:US
Practice Address - Phone:424-331-5661
Practice Address - Fax:310-760-2033
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-01
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61291225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist