Healthcare Provider Details

I. General information

NPI: 1588199541
Provider Name (Legal Business Name): MARIO GODINEZ CADCII, CDVC, CAMS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2017
Last Update Date: 04/26/2024
Certification Date: 04/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10953 RAMONA BLVD
EL MONTE CA
91731-1319
US

IV. Provider business mailing address

10953 RAMONA BLVD
EL MONTE CA
91731-2629
US

V. Phone/Fax

Practice location:
  • Phone: 626-434-2723
  • Fax: 626-279-2532
Mailing address:
  • Phone: 626-434-2723
  • Fax: 626-279-2532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC25171214
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: