Healthcare Provider Details

I. General information

NPI: 1104496009
Provider Name (Legal Business Name): ALEJANDRO LUJANO BOCO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 07/01/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1835 CHICAGO AVE STE A
RIVERSIDE CA
92507-2309
US

IV. Provider business mailing address

15271 COLUMBIA LN
HUNTINGTON BEACH CA
92647-2528
US

V. Phone/Fax

Practice location:
  • Phone: 909-477-3117
  • Fax: 909-303-9244
Mailing address:
  • Phone: 949-510-4176
  • Fax: 951-394-7411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberC51121
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: