Healthcare Provider Details

I. General information

NPI: 1194412643
Provider Name (Legal Business Name): DAMIEN JOSEPH SPENA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 N BUSH ST
SANTA ANA CA
92706-2816
US

IV. Provider business mailing address

4441 VICTORIA ST
CHINO CA
91710-2122
US

V. Phone/Fax

Practice location:
  • Phone: 714-361-7950
  • Fax:
Mailing address:
  • Phone: 909-927-7062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number40146
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: