Healthcare Provider Details

I. General information

NPI: 1225899693
Provider Name (Legal Business Name): LUIS ALBERTO MONTEON BECERRA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 RESERVOIR DR STE 204A
SAN DIEGO CA
92120-5134
US

IV. Provider business mailing address

5555 RESERVOIR DR STE 204A
SAN DIEGO CA
92120-5134
US

V. Phone/Fax

Practice location:
  • Phone: 619-822-1800
  • Fax: 619-839-3872
Mailing address:
  • Phone: 619-822-1800
  • Fax: 619-839-3872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: