Healthcare Provider Details

I. General information

NPI: 1700301736
Provider Name (Legal Business Name): ILCE SERRANO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2017
Last Update Date: 08/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 S GRAND AVE
LOS ANGELES CA
90015-3010
US

IV. Provider business mailing address

1611 KEARNEY ST
LOS ANGELES CA
90033-2311
US

V. Phone/Fax

Practice location:
  • Phone: 213-742-5822
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: