Basic Information
| Provider Information | |||||||||
| NPI: | 1730308461 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARBAJAL | ||||||||
| FirstName: | ALFONSO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13203 JUDD ST | ||||||||
| Address2: | |||||||||
| City: | PACOIMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913312423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188993312 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4211 AVALON BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900115622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234325185 | ||||||||
| FaxNumber: | 3234325086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.