Healthcare Provider Details

I. General information

NPI: 1467366161
Provider Name (Legal Business Name): EDDIE CHAVIRA CERVANTES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 E PALMDALE BLVD
PALMDALE CA
93550-4598
US

IV. Provider business mailing address

1030 LIGHTCAP ST
LANCASTER CA
93535-2771
US

V. Phone/Fax

Practice location:
  • Phone: 818-996-1051
  • Fax:
Mailing address:
  • Phone: 818-996-1051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-PTJQHD
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: