Healthcare Provider Details

I. General information

NPI: 1639536022
Provider Name (Legal Business Name): JENNIFER BALLESTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2016
Last Update Date: 01/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3807 W 187TH ST
TORRANCE CA
90504-5601
US

IV. Provider business mailing address

3807 W 187TH ST
TORRANCE CA
90504-5601
US

V. Phone/Fax

Practice location:
  • Phone: 310-989-9834
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberPT29732
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: