Healthcare Provider Details

I. General information

NPI: 1740607167
Provider Name (Legal Business Name): SHANE LENRE CALAGUAS AVILA NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2014
Last Update Date: 03/06/2026
Certification Date: 03/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4910 AIRPORT PLAZA DR STE 100
LONG BEACH CA
90815-1377
US

IV. Provider business mailing address

22734 MONETA AVE
CARSON CA
90745-3601
US

V. Phone/Fax

Practice location:
  • Phone: 562-429-2473
  • Fax:
Mailing address:
  • Phone: 702-579-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number95000320
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number95000320
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95000320
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: