Healthcare Provider Details

I. General information

NPI: 1912579566
Provider Name (Legal Business Name): MIGUEL ANGEL MUNOZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2021
Last Update Date: 03/11/2024
Certification Date: 03/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 S E ST STE 250
SAN BERNARDINO CA
92408-2706
US

IV. Provider business mailing address

2080 S E ST
SAN BERNARDINO CA
92408-2773
US

V. Phone/Fax

Practice location:
  • Phone: 909-433-9300
  • Fax:
Mailing address:
  • Phone: 909-433-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: