Basic Information
| Provider Information | |||||||||
| NPI: | 1073256558 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AREVALO | ||||||||
| FirstName: | LUISA | ||||||||
| MiddleName: | FERNANDA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1403 LOMITA BLVD STE 102 | ||||||||
| Address2: | |||||||||
| City: | HARBOR CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907102084 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1403 LOMITA BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | HARBOR CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907102086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106022550 | ||||||||
| FaxNumber: | 3102574991 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2022 | ||||||||
| LastUpdateDate: | 08/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.