Healthcare Provider Details

I. General information

NPI: 1558293522
Provider Name (Legal Business Name): ALEX ANTONIO HENRIQUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13330 VAUGHN ST
SAN FERNANDO CA
91340-2216
US

IV. Provider business mailing address

13330 VAUGHN ST
SAN FERNANDO CA
91340-2216
US

V. Phone/Fax

Practice location:
  • Phone: 818-896-7461
  • Fax:
Mailing address:
  • Phone: 818-896-7461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number35F8E25B52
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: