Provider Demographics
NPI:1952343667
Name:IGNACIO, CRYSTAL URATA LABRADOR (MSPT)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:URATA LABRADOR
Last Name:IGNACIO
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:MISS
Other - First Name:CRYSTAL
Other - Middle Name:URATA
Other - Last Name:LABRADOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:408 HIGUERA ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6135
Mailing Address - Country:US
Mailing Address - Phone:805-788-0805
Mailing Address - Fax:805-788-0845
Practice Address - Street 1:35325 DATE PALM DR STE 131
Practice Address - Street 2:
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-7031
Practice Address - Country:US
Practice Address - Phone:760-202-0368
Practice Address - Fax:760-770-1973
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK129195225100000X
TX1152481225100000X
CAPT294483225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T8753OtherBCBS
TX8K4615Medicare PIN