Healthcare Provider Details

I. General information

NPI: 1588953079
Provider Name (Legal Business Name): MR. JOSE JOVELLANOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2011
Last Update Date: 04/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

H100 SANTA MARGARITA RD
CAMP PENDLETON CA
92055-5191
US

IV. Provider business mailing address

36860 RED OAK ST
WINCHESTER CA
92596-9192
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-1495
  • Fax:
Mailing address:
  • Phone: 951-719-4393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: