=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558185959
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUAN P CHAVEZ SUDRC#15723
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2024
-----------------------------------------------------
Last Update Date | 11/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1701 ZONAL AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90033-1065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-223-6298
-----------------------------------------------------
Fax | 323-223-6399
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2830 LANFRANCO ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90033-4413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-534-9422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 15723
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------