Healthcare Provider Details

I. General information

NPI: 1477158590
Provider Name (Legal Business Name): LUIS CEDANO RADT-1
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2020
Last Update Date: 12/04/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6302 THIRTEENTH AVE
LUCERNE CA
95458
US

IV. Provider business mailing address

PO BOX 1024
LUCERNE CA
95458-1024
US

V. Phone/Fax

Practice location:
  • Phone: 707-274-9101
  • Fax: 707-274-9192
Mailing address:
  • Phone: 707-274-9101
  • Fax: 707-274-9192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: