Healthcare Provider Details

I. General information

NPI: 1568842763
Provider Name (Legal Business Name): JUAN A VELAZQUEZ COMUNITY WORKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JUAN A VELAZQUEZ 172V00000X

II. Dates (important events)

Enumeration Date: 06/02/2015
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 OCEANGATE STE 550
LONG BEACH CA
90802-4312
US

IV. Provider business mailing address

100 OCEANGATE SUITE 550
LONG BEACH CA
90802-4312
US

V. Phone/Fax

Practice location:
  • Phone: 310-951-6829
  • Fax:
Mailing address:
  • Phone: 562-435-3037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: