MEDICARE: LUIS HUMBERTO PROANO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	92403	CA

General Provider Information

NPI Number	:	1447868963
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUIS HUMBERTO PROANO

Provider Business Mailing Address
First Line	:	316 S GERHART AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90022-2353
Country	:	US
Telephone Number	:	323-519-2462
Fax Number	:

Provider Business Practice Location Address
First Line	:	4969 W SUNSET BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90027-5813
Country	:	US
Telephone Number	:	213-905-2143
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2020
Last Update Date	:	07/21/2020

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