Healthcare Provider Details

I. General information

NPI: 1942873781
Provider Name (Legal Business Name): CONSUELO CISNEROS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 08/02/2023
Certification Date: 08/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1339 20TH ST
SANTA MONICA CA
90404-2033
US

IV. Provider business mailing address

1339 20TH ST
SANTA MONICA CA
90404-2033
US

V. Phone/Fax

Practice location:
  • Phone: 310-829-8921
  • Fax:
Mailing address:
  • Phone: 310-829-8921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: