Provider Demographics
NPI:1801267620
Name:MAYORALGO, RAQUEL DACLISON (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:MRS
First Name:RAQUEL
Middle Name:DACLISON
Last Name:MAYORALGO
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 605
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91788-0605
Mailing Address - Country:US
Mailing Address - Phone:626-646-8845
Mailing Address - Fax:
Practice Address - Street 1:416 N GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-1203
Practice Address - Country:US
Practice Address - Phone:626-280-0280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22504225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist