Healthcare Provider Details

I. General information

NPI: 1386768489
Provider Name (Legal Business Name): ERANIO GARCHITORENA CORDOVA JR. LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 05/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6301 BEACH BLVD STE 245
BUENA PARK CA
90621-4031
US

IV. Provider business mailing address

948 N MOHAWK AVE
ANAHEIM CA
92801-3508
US

V. Phone/Fax

Practice location:
  • Phone: 714-736-0231
  • Fax: 714-736-0895
Mailing address:
  • Phone: 714-776-8840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS29182
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: