Healthcare Provider Details

I. General information

NPI: 1497176267
Provider Name (Legal Business Name): CALEB PICO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2013
Last Update Date: 12/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12235 BEACH BLVD SUITE 107
STANTON CA
90680-3939
US

IV. Provider business mailing address

12235 BEACH BLVD SUITE 107
STANTON CA
90680-3939
US

V. Phone/Fax

Practice location:
  • Phone: 714-891-2601
  • Fax: 714-798-2266
Mailing address:
  • Phone: 714-891-2601
  • Fax: 714-798-2266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number2069
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: