Healthcare Provider Details

I. General information

NPI: 1669954400
Provider Name (Legal Business Name): LORENA FAJARDO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2018
Last Update Date: 08/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1776 E CENTURY BOLVD
LOS ANGELES CA
90002
US

IV. Provider business mailing address

1776 E CENTURY BOLVD
LOS ANGELES CA
90002
US

V. Phone/Fax

Practice location:
  • Phone: 323-374-6848
  • Fax: 323-374-6691
Mailing address:
  • Phone: 323-374-6848
  • Fax: 323-374-6691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: