Healthcare Provider Details

I. General information

NPI: 1790444602
Provider Name (Legal Business Name): JOHN T. SIMMONS JR. LVN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2021
Last Update Date: 03/18/2024
Certification Date: 03/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5020 E HOLBROOK ST
ANAHEIM CA
92807-1103
US

IV. Provider business mailing address

5020 E HOLBROOK ST
ANAHEIM CA
92807-1103
US

V. Phone/Fax

Practice location:
  • Phone: 714-261-5392
  • Fax:
Mailing address:
  • Phone: 714-261-5392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number281328
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: