Healthcare Provider Details

I. General information

NPI: 1942606389
Provider Name (Legal Business Name): GUADALUPE OTANEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2014
Last Update Date: 11/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29325 KIMBERLINA ROAD
WASCO CA
93280
US

IV. Provider business mailing address

29325 KIMBERLINA RD
WASCO CA
93280
US

V. Phone/Fax

Practice location:
  • Phone: 661-758-4029
  • Fax:
Mailing address:
  • Phone: 661-758-4029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: