Healthcare Provider Details

I. General information

NPI: 1952900060
Provider Name (Legal Business Name): MIKAEL JOSEPH AURO GODISAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2020
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12235 BEACH BLVD
STANTON CA
90680-3939
US

IV. Provider business mailing address

16537 GARNET WAY
CHINO HILLS CA
91709-4926
US

V. Phone/Fax

Practice location:
  • Phone: 714-202-0118
  • Fax:
Mailing address:
  • Phone: 909-696-1180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: