Healthcare Provider Details

I. General information

NPI: 1568161180
Provider Name (Legal Business Name): LUIS ANTONIO HERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2023
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 N 8TH ST
EL CENTRO CA
92243-2302
US

IV. Provider business mailing address

202 N 8TH ST
EL CENTRO CA
92243-2302
US

V. Phone/Fax

Practice location:
  • Phone: 442-265-7200
  • Fax: 442-265-7206
Mailing address:
  • Phone: 442-265-7200
  • Fax: 442-265-7206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: