Healthcare Provider Details

I. General information

NPI: 1932020732
Provider Name (Legal Business Name): THERON DEAN PAGE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2026
Last Update Date: 07/25/2026
Certification Date: 07/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1968 S COAST HWY STE 1390
LAGUNA BEACH CA
92651-3681
US

IV. Provider business mailing address

18450 ARMINTA ST APT 108
RESEDA CA
91335-2015
US

V. Phone/Fax

Practice location:
  • Phone: 800-430-4490
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: