Provider Demographics
NPI:1740308154
Name:BANZUELA, ALVIN LAZARO (PT)
Entity type:Individual
Prefix:MR
First Name:ALVIN
Middle Name:LAZARO
Last Name:BANZUELA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:THERA-
Other - Middle Name:
Other - Last Name:PRN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2427 GRAMERCY AVE
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501-4445
Mailing Address - Country:US
Mailing Address - Phone:310-328-1084
Mailing Address - Fax:
Practice Address - Street 1:2427 GRAMERCY AVE
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90501-4445
Practice Address - Country:US
Practice Address - Phone:310-328-1084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT24628225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist