Healthcare Provider Details

I. General information

NPI: 1497184139
Provider Name (Legal Business Name): FABIAN BARAJAS GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2013
Last Update Date: 10/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21520 PIONEER BLVD STE 203
HAWAIIAN GARDENS CA
90716-2601
US

IV. Provider business mailing address

6762 LEXINGTON AVE
LOS ANGELES CA
90038-1217
US

V. Phone/Fax

Practice location:
  • Phone: 562-865-3644
  • Fax:
Mailing address:
  • Phone: 323-380-7590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: