Basic Information
| Provider Information | |||||||||
| NPI: | 1306410840 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BELTRAN | ||||||||
| FirstName: | GUADALUPE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7108 S KANNER HWY | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349977462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558326727 | ||||||||
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| Practice Location | |||||||||
| Address1: | 31889 CALLE LUZ # 2 | ||||||||
| Address2: | |||||||||
| City: | TEMECULA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925923926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558326727 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2021 | ||||||||
| LastUpdateDate: | 10/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X | CA | Y | Technologists, Technicians & Other Technical Service Providers | Technician, Other |
ID Information
| ID | Type | State | Issuer | Description | 247200000X | 05 | CA | MEDICAID |