Healthcare Provider Details

I. General information

NPI: 1669082434
Provider Name (Legal Business Name): JEROME PRUDENCIO JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2020
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 S FAIRFAX AVE FL 2
LOS ANGELES CA
90036-2166
US

IV. Provider business mailing address

8816 LA RIVIERA DR UNIT D
SACRAMENTO CA
95826-2075
US

V. Phone/Fax

Practice location:
  • Phone: 310-502-8089
  • Fax:
Mailing address:
  • Phone: 310-502-8089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: