Healthcare Provider Details

I. General information

NPI: 1073235685
Provider Name (Legal Business Name): CANDACE QUATINA BUTLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2022
Last Update Date: 09/12/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13790 ROCKPORT COURT
MORENO VALLEY CA
92553
US

IV. Provider business mailing address

5505 E SANTA ANA CANYON RD
ANAHEIM CA
92817-1200
US

V. Phone/Fax

Practice location:
  • Phone: 310-920-3400
  • Fax:
Mailing address:
  • Phone: 310-920-3400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number334700412
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: