Healthcare Provider Details

I. General information

NPI: 1154821171
Provider Name (Legal Business Name): JOHN ERICK MADRID LASCANO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2018
Last Update Date: 07/18/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E. DEL MAR BLVD SUITE 112
PASADENA CA
91105
US

IV. Provider business mailing address

295 89TH ST SUITE 306
DALY CITY CA
94015
US

V. Phone/Fax

Practice location:
  • Phone: 949-203-8875
  • Fax:
Mailing address:
  • Phone: 877-264-6747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: