Healthcare Provider Details

I. General information

NPI: 1316794605
Provider Name (Legal Business Name): CIRILO BARAJAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2024
Last Update Date: 06/25/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3125 N BROADWAY
LOS ANGELES CA
90031-2703
US

IV. Provider business mailing address

3125 N BROADWAY
LOS ANGELES CA
90031-2703
US

V. Phone/Fax

Practice location:
  • Phone: 213-215-3017
  • Fax:
Mailing address:
  • Phone: 213-215-3017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number724176
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: