Healthcare Provider Details

I. General information

NPI: 1336852763
Provider Name (Legal Business Name): JOHN FARRAGE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2022
Last Update Date: 12/30/2022
Certification Date: 12/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 W 14TH ST
SAN PEDRO CA
90731-4337
US

IV. Provider business mailing address

2033 S CRESCENT AVE
SAN PEDRO CA
90731-5512
US

V. Phone/Fax

Practice location:
  • Phone: 310-519-8723
  • Fax:
Mailing address:
  • Phone: 310-519-8723
  • Fax: 310-519-1309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1493871222
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberR1493871222
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: