Healthcare Provider Details

I. General information

NPI: 1760139489
Provider Name (Legal Business Name): EVELYN ELIZALDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2022
Last Update Date: 07/21/2023
Certification Date: 07/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 N EL CENTRO AVE
LOS ANGELES CA
90038-3805
US

IV. Provider business mailing address

5020 MCKINLEY AVE
LOS ANGELES CA
90011-4026
US

V. Phone/Fax

Practice location:
  • Phone: 323-384-5150
  • Fax:
Mailing address:
  • Phone: 323-613-5466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: