Provider Demographics
NPI:1780290353
Name:TOLENTINO, EAN KENNETH LLANDA
Entity type:Individual
Prefix:MR
First Name:EAN KENNETH
Middle Name:LLANDA
Last Name:TOLENTINO
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 1:2016 TUPELO WAY
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-9366
Mailing Address - Country:US
Mailing Address - Phone:925-759-2544
Mailing Address - Fax:
Practice Address - Street 1:3130 WILSHIRE BLVD STE 409
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-1206
Practice Address - Country:US
Practice Address - Phone:213-389-1004
Practice Address - Fax:213-263-2131
Is Sole Proprietor?:No
Enumeration Date:2020-09-19
Last Update Date:2020-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21583225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANAMedicaid