Healthcare Provider Details

I. General information

NPI: 1790187482
Provider Name (Legal Business Name): ANGEL RAY AGUDO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2014
Last Update Date: 02/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 S 11TH ST
SAN JOSE CA
95112-2135
US

IV. Provider business mailing address

1470 W 6TH ST
SAN BERNARDINO CA
92411-2678
US

V. Phone/Fax

Practice location:
  • Phone: 909-835-5233
  • Fax:
Mailing address:
  • Phone: 909-835-5233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: