Healthcare Provider Details

I. General information

NPI: 1871741553
Provider Name (Legal Business Name): RUDOLPHO PEREZ MSW INTERN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2008
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 MYRTLE AVE
INGLEWOOD CA
90301
US

IV. Provider business mailing address

4760 S. SEPULVEDA BLVD
CULVER CITY CA
90230
US

V. Phone/Fax

Practice location:
  • Phone: 310-412-4131
  • Fax:
Mailing address:
  • Phone: 310-412-4191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number89427
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number91751
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: