Healthcare Provider Details

I. General information

NPI: 1245866565
Provider Name (Legal Business Name): MR. JOSHUA ADOLFO VELASQUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2020
Last Update Date: 03/18/2020
Certification Date: 03/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

849 N RIDGEWOOD PL
LOS ANGELES CA
90038-4302
US

IV. Provider business mailing address

849 N RIDGEWOOD PL
LOS ANGELES CA
90038-4302
US

V. Phone/Fax

Practice location:
  • Phone: 424-666-7108
  • Fax:
Mailing address:
  • Phone: 424-666-7108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: