Healthcare Provider Details

I. General information

NPI: 1730431966
Provider Name (Legal Business Name): ERNIE JOHN TAIMANGLO LAADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2012
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

338 W LEXINGTON AVE
EL CAJON CA
92020-4465
US

IV. Provider business mailing address

741 CARLOW CT
EL CAJON CA
92020-2011
US

V. Phone/Fax

Practice location:
  • Phone: 619-255-5499
  • Fax:
Mailing address:
  • Phone: 619-750-5871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLR05710121
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number091760-III
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: