Healthcare Provider Details

I. General information

NPI: 1528829173
Provider Name (Legal Business Name): JUVID CEBALLOS VIRTUDES RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 01/22/2024
Certification Date: 01/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2289 ROOT ST
FULLERTON CA
92833-2108
US

IV. Provider business mailing address

2289 ROOT ST
FULLERTON CA
92833-2108
US

V. Phone/Fax

Practice location:
  • Phone: 714-261-0908
  • Fax:
Mailing address:
  • Phone: 714-261-0908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number95086357
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: