Provider Demographics
NPI:1548256829
Name:ROMERO, CARLOS YANCEY (MPT)
Entity type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:YANCEY
Last Name:ROMERO
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:CARLOS
Other - Middle Name:
Other - Last Name:ROMERO MPT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:12139 MOUNT VERNON AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5586
Mailing Address - Country:US
Mailing Address - Phone:909-370-3396
Mailing Address - Fax:909-783-4288
Practice Address - Street 1:10537 MAGNOLIA BLVD
Practice Address - Street 2:REHAB DEPT
Practice Address - City:N HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91601-4114
Practice Address - Country:US
Practice Address - Phone:818-508-9293
Practice Address - Fax:818-508-9293
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT29686225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT296880Medicaid