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Provider Information for 1063593648

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1063593648

Calendar   Last Updated:  2017-06-27
  Certification Date: 


Name Value
NPI 1063593648
Enumeration Date 2006-10-18
NPI Type 1 - Individual
Sole Proprietor YES
Status Active
Mailing Address 1745 W ORANGEWOOD AVE SUITE 103
ORANGE, CA 92868-2004
United States

Phone: | Fax:
View Map External Link
Primary Practice Address 291 CERRITOS AVE
LONG BEACH, CA 90802-3429
United States

Phone: 714-469-8573 | Fax:
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 171M00000X - Case Manager/Care Coordinator
No 101YM0800X - Counselor Mental Health