Provider Demographics
NPI:1801927421
Name:MELLIBOSKY, CHRISTIAN ANDRES (RPT)
Entity type:Individual
Prefix:MR
First Name:CHRISTIAN
Middle Name:ANDRES
Last Name:MELLIBOSKY
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19573 PINE VALLEY AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91326-1465
Mailing Address - Country:US
Mailing Address - Phone:818-723-0724
Mailing Address - Fax:
Practice Address - Street 1:909 LUCILE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-1511
Practice Address - Country:US
Practice Address - Phone:323-663-8281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14593225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist