Healthcare Provider Details

I. General information

NPI: 1023294865
Provider Name (Legal Business Name): EUGENE HERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2008
Last Update Date: 01/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4211 AVALON BLVD
LOS ANGELES CA
90011-5622
US

IV. Provider business mailing address

13406 ELDRIDGE AVE
SYLMAR CA
91342-2336
US

V. Phone/Fax

Practice location:
  • Phone: 323-432-5185
  • Fax: 323-432-5086
Mailing address:
  • Phone:
  • Fax:

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: