Healthcare Provider Details

I. General information

NPI: 1053087502
Provider Name (Legal Business Name): ANDRES IVAN BOQUIREN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2021
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3491 KURTZ ST STE 150
SAN DIEGO CA
92110-4430
US

IV. Provider business mailing address

1055 E COLORADO BLVD STE 560
PASADENA CA
91106-2380
US

V. Phone/Fax

Practice location:
  • Phone: 619-320-2404
  • Fax:
Mailing address:
  • Phone: 818-241-6780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: