=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194598912
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SERGIO MIJAIL ALVAREZ ND
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2023
-----------------------------------------------------
Last Update Date | 11/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4651 GAGE AVE STE E
-----------------------------------------------------
City | BELL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90201-1371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-684-9165
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4651 GAGE AVE STE E
-----------------------------------------------------
City | BELL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90201-1371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-684-9165
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 42220491
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------