Healthcare Provider Details

I. General information

NPI: 1710125786
Provider Name (Legal Business Name): JAIME EMMANUEL FAJARDO LVN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2009
Last Update Date: 01/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3126 GLENROSE AVE
ALTADENA CA
91001-4328
US

IV. Provider business mailing address

901 S KINGSLEY DR APT. 307
LOS ANGELES CA
90006-1291
US

V. Phone/Fax

Practice location:
  • Phone: 626-296-9812
  • Fax: 626-296-9818
Mailing address:
  • Phone: 213-385-6005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number236322
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: