Healthcare Provider Details

I. General information

NPI: 1558099978
Provider Name (Legal Business Name): JUDE MERAZ SUD/CHW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2022
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7344 MAGNOLIA AVE STE 110
RIVERSIDE CA
92504-3819
US

IV. Provider business mailing address

5320 S BROADWAY
LOS ANGELES CA
90037-3808
US

V. Phone/Fax

Practice location:
  • Phone: 951-404-0856
  • Fax:
Mailing address:
  • Phone: 323-325-7510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number21929
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: