Individual
MICAH EBANCULLA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
1600 ATLANTIC AVE, LONG BEACH, CA 90813-2017
(562) 591-0581
Mailing address
5503 PIMENTA AVE, LAKEWOOD, CA 90712-1743
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
—
—
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
03/07/2018
Last updated
05/03/2021
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