Healthcare Provider Details

I. General information

NPI: 1861030082
Provider Name (Legal Business Name): MILES LAGUNAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2019
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

871 COLEMAN AVE # 209
SAN JOSE CA
95110-1831
US

IV. Provider business mailing address

1663 MISSION ST STE 400
SAN FRANCISCO CA
94103-2485
US

V. Phone/Fax

Practice location:
  • Phone: 877-264-6747
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: