Healthcare Provider Details

I. General information

NPI: 1346823614
Provider Name (Legal Business Name): ROBERTO JAMES NELSON BALDERAS-FOWLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2021
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 VETERAN AVE RM 25-57
LOS ANGELES CA
90095-1048
US

IV. Provider business mailing address

1000 VETERAN AVE RM 25-57
LOS ANGELES CA
90024-2704
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-6110
  • Fax:
Mailing address:
  • Phone: 866-523-4268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
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: