Healthcare Provider Details

I. General information

NPI: 1629345509
Provider Name (Legal Business Name): JUCEVI VIRTUDES FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2011
Last Update Date: 11/27/2023
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 EASTLAKE AVE
LOS ANGELES CA
90089-1019
US

IV. Provider business mailing address

PO BOX 31309
LOS ANGELES CA
90031-0309
US

V. Phone/Fax

Practice location:
  • Phone: 323-865-3000
  • Fax:
Mailing address:
  • Phone: 323-865-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number20900
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number20900
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: