Healthcare Provider Details

I. General information

NPI: 1962238014
Provider Name (Legal Business Name): LUIS TINAJERO PEREA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2024
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 S ANITA DR STE 102-104
ORANGE CA
92868-3355
US

IV. Provider business mailing address

265 S ANITA DR STE 102-104
ORANGE CA
92868-3355
US

V. Phone/Fax

Practice location:
  • Phone: 714-410-3500
  • Fax:
Mailing address:
  • Phone: 714-410-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: