MEDICARE: MR. ROBERTO RUBALCABA

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1679758270
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERTO RUBALCABA

Provider Business Mailing Address
First Line	:	3525 RAMBOZ DR
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90063-2025
Country	:	US
Telephone Number	:	323-269-9741
Fax Number	:

Provider Business Practice Location Address
First Line	:	3525 RAMBOZ DR
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90063-2025
Country	:	US
Telephone Number	:	323-269-9741
Fax Number	:

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

Provider Enumeration Date	:	01/02/2008
Last Update Date	:	01/02/2008

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