Healthcare Provider Details

I. General information

NPI: 1962808865
Provider Name (Legal Business Name): CEASAR CORONA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2014
Last Update Date: 06/02/2023
Certification Date: 06/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 BAIRD AVE
RESEDA CA
91335-4150
US

IV. Provider business mailing address

6819 HINDS AVE
NORTH HOLLYWOOD CA
91605-6009
US

V. Phone/Fax

Practice location:
  • Phone: 818-342-5897
  • Fax: 818-975-5008
Mailing address:
  • Phone: 818-342-5897
  • Fax: 818-975-5008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberB00002281221
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: