Healthcare Provider Details

I. General information

NPI: 1750912994
Provider Name (Legal Business Name): NATHAN SAMUEL PERDOMO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2020
Last Update Date: 03/05/2020
Certification Date: 03/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 S ARROYO PKWY
PASADENA CA
91105-3911
US

IV. Provider business mailing address

1692 PUENTE AVE
BALDWIN PARK CA
91706-5956
US

V. Phone/Fax

Practice location:
  • Phone: 626-403-2794
  • Fax:
Mailing address:
  • Phone: 626-484-7941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: