Healthcare Provider Details

I. General information

NPI: 1942621289
Provider Name (Legal Business Name): MARIO FRANCISCO CEA RW7269
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2014
Last Update Date: 01/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 E. 17TH STREET SUIT, B
SANTA ANA CA
92705
US

IV. Provider business mailing address

1525 E. 17TH STREET, SUITE B
SANTA ANA CA
92705
US

V. Phone/Fax

Practice location:
  • Phone: 714-542-0400
  • Fax: 714-542-0404
Mailing address:
  • Phone: 714-542-0400
  • Fax: 714-542-0404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRW7269
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: