Healthcare Provider Details

I. General information

NPI: 1679104749
Provider Name (Legal Business Name): JUAQUIN ZAVALA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2020
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16436 1/2 ORIZABA AVE
PARAMOUNT CA
90723
US

IV. Provider business mailing address

13428 MAXELLA AVE STE 913
MARINA DEL REY CA
90292-5620
US

V. Phone/Fax

Practice location:
  • Phone: 424-272-5238
  • Fax:
Mailing address:
  • Phone: 424-272-5238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: