Provider Demographics
NPI:1952894669
Name:VALENCIA, KRISTOFFER (PTA)
Entity type:Individual
Prefix:
First Name:KRISTOFFER
Middle Name:
Last Name:VALENCIA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 W 11TH ST APT 405
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-2232
Mailing Address - Country:US
Mailing Address - Phone:858-354-1092
Mailing Address - Fax:
Practice Address - Street 1:1900 E SLAUSON AVE STE B
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-2725
Practice Address - Country:US
Practice Address - Phone:323-277-7678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-08
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49332225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant