Healthcare Provider Details

I. General information

NPI: 1669603445
Provider Name (Legal Business Name): MR. ANTONIO NEVAREZ PENUELAS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2009
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 WEST CHESTNUT AVE
LOMPOC CA
93436
US

IV. Provider business mailing address

PO BOX 221433
SACRAMENTO CA
95822-8433
US

V. Phone/Fax

Practice location:
  • Phone: 805-740-4555
  • Fax: 805-740-4558
Mailing address:
  • Phone: 916-207-2315
  • Fax: 866-379-0937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: