Healthcare Provider Details

I. General information

NPI: 1285387258
Provider Name (Legal Business Name): JUAN MANUEL AMEZCUA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2022
Last Update Date: 01/15/2026
Certification Date: 01/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44459 10TH ST W
LANCASTER CA
93534-3324
US

IV. Provider business mailing address

43013 38TH ST W
LANCASTER CA
93536-4905
US

V. Phone/Fax

Practice location:
  • Phone: 661-726-2630
  • Fax:
Mailing address:
  • Phone: 661-495-8384
  • 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 Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: