Basic Information
Provider Information | |||||||||
NPI: | 1447728738 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ALCANTAR | ||||||||
FirstName: | AZUCENA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RAYA MEJIA | ||||||||
OtherFirstName: | AZUCENA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 21600 OXNARD ST STE 1800 | ||||||||
Address2: |   | ||||||||
City: | WOODLAND HILLS | ||||||||
State: | CA | ||||||||
PostalCode: | 913677807 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8183452345 | ||||||||
FaxNumber: | 0000000000 | ||||||||
Practice Location | |||||||||
Address1: | 1730 W. WALNUT AVENUE, SUITE A | ||||||||
Address2: |   | ||||||||
City: | VISALIA | ||||||||
State: | CA | ||||||||
PostalCode: | 93277 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5598258455 | ||||||||
FaxNumber: | 0000000000 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/05/2018 | ||||||||
LastUpdateDate: | 11/05/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | F3294872 | CA | Y |   |   |   |   |
No ID Information.