Healthcare Provider Details

I. General information

NPI: 1104342179
Provider Name (Legal Business Name): JOHN CONTRERAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2017
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date: 06/22/2026
Reactivation Date: 07/29/2026

III. Provider practice location address

4211 AVALON BLVD
LOS ANGELES CA
90011-5622
US

IV. Provider business mailing address

4211 AVALON BLVD
LOS ANGELES CA
90011-5622
US

V. Phone/Fax

Practice location:
  • Phone: 323-886-5081
  • Fax: 323-582-2251
Mailing address:
  • Phone: 323-582-2251
  • Fax: 323-582-2251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: