Provider Demographics
NPI:1780693408
Name:TAEZA, DOREENA FE VIDUYA (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:DOREENA FE
Middle Name:VIDUYA
Last Name:TAEZA
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 W IMPERIAL AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-2102
Mailing Address - Country:US
Mailing Address - Phone:310-651-0676
Mailing Address - Fax:
Practice Address - Street 1:13922 CERISE AVE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-8688
Practice Address - Country:US
Practice Address - Phone:310-675-3304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32855225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic