Healthcare Provider Details

I. General information

NPI: 1992224646
Provider Name (Legal Business Name): CARLOS EDUARDO JUAREZ AGUILAR OCCUPATIONAL THERAPI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2017
Last Update Date: 07/07/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 S BROADWAY
LOS ANGELES CA
90037-2729
US

IV. Provider business mailing address

4601 S BROADWAY
LOS ANGELES CA
90037-2729
US

V. Phone/Fax

Practice location:
  • Phone: 323-803-3881
  • Fax:
Mailing address:
  • Phone: 323-803-3881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number20728
License Number StateCA
# 2
Primary TaxonomyN
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: