Healthcare Provider Details

I. General information

NPI: 1407821275
Provider Name (Legal Business Name): JOVI CACNIO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 E ROUTE 66
GLENDORA CA
91740-4670
US

IV. Provider business mailing address

2025 E ROUTE 66
GLENDORA CA
91740-4670
US

V. Phone/Fax

Practice location:
  • Phone: 626-963-3681
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG071087
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: