Provider Demographics
NPI:1548852171
Name:MOULIC, MATHIEU JOSEPH AGBAYANI
Entity type:Individual
Prefix:
First Name:MATHIEU JOSEPH
Middle Name:AGBAYANI
Last Name:MOULIC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 EOLA DR
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-2249
Mailing Address - Country:US
Mailing Address - Phone:909-859-4410
Mailing Address - Fax:
Practice Address - Street 1:433 N 4TH ST STE 216
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4309
Practice Address - Country:US
Practice Address - Phone:323-530-0433
Practice Address - Fax:323-530-0434
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299815225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist