Healthcare Provider Details

I. General information

NPI: 1740455849
Provider Name (Legal Business Name): CARLOS MONTES DE OCA PAEZ B.S.- R.A.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 SHEPARD LN C
BISHOP CA
93514-2133
US

IV. Provider business mailing address

163C SHEPARD LN
BISHOP CA
93514-2133
US

V. Phone/Fax

Practice location:
  • Phone: 760-258-7132
  • Fax:
Mailing address:
  • Phone: 760-258-7132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberMO403021116
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberMO403021116
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberMO403021116
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: