MEDICARE: MR. JOSE DESTAJO RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WP0808X	Psychiatric/Mental Health Registered Nurse	745368	CA

General Provider Information

NPI Number	:	1528452778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOSE DESTAJO RN

Provider Business Mailing Address
First Line	:	9938 SWINTON AVE
Second Line	:
City	:	NORTH HILLS
State	:	CA
Zip	:	91343-1328
Country	:	US
Telephone Number	:	818-634-1077
Fax Number	:

Provider Business Practice Location Address
First Line	:	14238 SARANAC LN
Second Line	:
City	:	SYLMAR
State	:	CA
Zip	:	91342-1435
Country	:	US
Telephone Number	:	818-485-0888
Fax Number	:	818-833-5690

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/25/2015
Last Update Date	:	11/01/2022

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