Provider Demographics
NPI:1780700252
Name:BOMBASE, ALVIN ANSELMO CRUZ (RPT, CEAS)
Entity type:Individual
Prefix:
First Name:ALVIN ANSELMO
Middle Name:CRUZ
Last Name:BOMBASE
Suffix:
Gender:M
Credentials:RPT, CEAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16630 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-2716
Mailing Address - Country:US
Mailing Address - Phone:310-768-8155
Mailing Address - Fax:310-768-8313
Practice Address - Street 1:24920 WALNUT ST
Practice Address - Street 2:
Practice Address - City:LOMITA
Practice Address - State:CA
Practice Address - Zip Code:90717-1925
Practice Address - Country:US
Practice Address - Phone:310-293-7416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA282862251E1200X, 2251X0800X
CAPT28286225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomics
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic