Healthcare Provider Details

I. General information

NPI: 1124582655
Provider Name (Legal Business Name): MALLOLO RESENDES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2019
Last Update Date: 02/26/2021
Certification Date: 02/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 FLYNN RD
CAMARILLO CA
93012-8704
US

IV. Provider business mailing address

1914 LA PUERTA AVE
OXNARD CA
93030-5557
US

V. Phone/Fax

Practice location:
  • Phone: 805-445-7800
  • Fax:
Mailing address:
  • Phone: 805-607-2099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberD9781671
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: