Healthcare Provider Details

I. General information

NPI: 1548752413
Provider Name (Legal Business Name): MR. SERGIO NICHOLAS GUZMAN JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 06/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 N BROADWAY
BLYTHE CA
92225-1609
US

IV. Provider business mailing address

240 N BROADWAY
BLYTHE CA
92225-1609
US

V. Phone/Fax

Practice location:
  • Phone: 760-921-5860
  • Fax: 760-921-5886
Mailing address:
  • Phone: 760-921-5860
  • Fax: 760-921-5886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: