Healthcare Provider Details

I. General information

NPI: 1023415585
Provider Name (Legal Business Name): JUDY JEAN PERMEJO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2014
Last Update Date: 11/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 W 1ST ST
TUSTIN CA
92780-3004
US

IV. Provider business mailing address

6033 E CAMINO MANZANO
ANAHEIM CA
92807-3216
US

V. Phone/Fax

Practice location:
  • Phone: 714-617-4593
  • Fax:
Mailing address:
  • Phone: 714-322-6013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number35052
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number51350
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: