Healthcare Provider Details

I. General information

NPI: 1720373939
Provider Name (Legal Business Name): JUSTIN MANUEL AMARAL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2011
Last Update Date: 06/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 TAFT AVE
RICHMOND CA
94804-3449
US

IV. Provider business mailing address

180 RIVERVIEW DR
PITTSBURG CA
94565-5732
US

V. Phone/Fax

Practice location:
  • Phone: 510-235-3172
  • Fax:
Mailing address:
  • Phone: 925-519-1371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number075600636
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: