Healthcare Provider Details

I. General information

NPI: 1396598827
Provider Name (Legal Business Name): ENRIQUE CRISTOBAL MENESES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2024
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

762 GRISWOLD AVE
SAN FERNANDO CA
91340-2105
US

IV. Provider business mailing address

13500 FOOTHILL BLVD APT 201B
SYLMAR CA
91342-4455
US

V. Phone/Fax

Practice location:
  • Phone: 747-500-9405
  • Fax:
Mailing address:
  • Phone: 747-241-7520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number7286
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number7286
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: