Healthcare Provider Details

I. General information

NPI: 1619370582
Provider Name (Legal Business Name): SALVADOR VELASCO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2014
Last Update Date: 03/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11401 BLOOMFIELD AVENUE CEDAR STREET
NORWALK CA
90650
US

IV. Provider business mailing address

11401 BLOOMFIELD AVE CEDAR STREET
NORWALK CA
90650-2015
US

V. Phone/Fax

Practice location:
  • Phone: 310-337-7417
  • Fax:
Mailing address:
  • Phone: 310-337-7417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW69844
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: