Healthcare Provider Details

I. General information

NPI: 1144466459
Provider Name (Legal Business Name): EDWIN JESUS HUACO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2008
Last Update Date: 12/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26081 MOCINE AVE
HAYWARD CA
94544-2923
US

IV. Provider business mailing address

26081 MOCINE AVENUE
HAYWARD CA
94544
US

V. Phone/Fax

Practice location:
  • Phone: 510-881-5921
  • Fax: 510-881-5925
Mailing address:
  • Phone: 510-881-5921
  • Fax: 510-881-5925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: