Healthcare Provider Details

I. General information

NPI: 1053549840
Provider Name (Legal Business Name): LUIS CUELLAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 CHADBOURNE RD
FAIRFIELD CA
94534-9639
US

IV. Provider business mailing address

2275 ARLINGTON DR
SAN LEANDRO CA
94578-1132
US

V. Phone/Fax

Practice location:
  • Phone: 510-317-1444
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number109043
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number109043
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: