Healthcare Provider Details

I. General information

NPI: 1841102811
Provider Name (Legal Business Name): FREDY INOCENCIO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6330 RUGBY AVE STE 200
HUNTINGTON PARK CA
90255-6938
US

IV. Provider business mailing address

4231 E CESAR E CHAVEZ AVE
LOS ANGELES CA
90063-3417
US

V. Phone/Fax

Practice location:
  • Phone: 323-705-5992
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: