Healthcare Provider Details

I. General information

NPI: 1003746652
Provider Name (Legal Business Name): ROBERTO CARMONA-VERGARA ASW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11301 WILSHIRE BLVD
LOS ANGELES CA
90073-1003
US

IV. Provider business mailing address

4138 WALNUT ST
BALDWIN PARK CA
91706-2907
US

V. Phone/Fax

Practice location:
  • Phone: 310-478-3711
  • Fax:
Mailing address:
  • Phone: 626-474-0615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW132473
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: