Healthcare Provider Details

I. General information

NPI: 1427675404
Provider Name (Legal Business Name): CESAR CARMONA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 NUTMEG PL STE 110
COSTA MESA CA
92626-2557
US

IV. Provider business mailing address

1055 E COLORADO BLVD STE 560
PASADENA CA
91106-2380
US

V. Phone/Fax

Practice location:
  • Phone: 949-910-6767
  • Fax: 877-268-3922
Mailing address:
  • Phone: 818-241-6780
  • Fax: 818-241-6853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: