Healthcare Provider Details

I. General information

NPI: 1013456979
Provider Name (Legal Business Name): SAMUEL MALDONADO JR. BOCO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2017
Last Update Date: 02/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2151 N. HARBOR BLVD SUITE 1200
FULLERTON CA
92835-3821
US

IV. Provider business mailing address

2151 N. HARBOR BLVD SUITE 1200
FULLERTON CA
92835-3821
US

V. Phone/Fax

Practice location:
  • Phone: 714-871-9960
  • Fax: 714-871-9965
Mailing address:
  • Phone: 714-871-9960
  • Fax: 714-871-9965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberC50102
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: