Healthcare Provider Details

I. General information

NPI: 1306347976
Provider Name (Legal Business Name): MR. HERBERT ALONSO GARCILAZO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2018
Last Update Date: 01/09/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

795 FOLSOM ST FL 1
SAN FRANCISCO CA
94107-4226
US

IV. Provider business mailing address

3586 LOVEBIRD WAY
ANTIOCH CA
94509-6458
US

V. Phone/Fax

Practice location:
  • Phone: 855-832-6727
  • Fax: 772-675-9100
Mailing address:
  • Phone: 925-783-0706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-39483
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: