MEDICARE: MARK RAYMOND ALTRE

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	164X00000X	Licensed Vocational Nurse	267137	CA

General Provider Information

NPI Number	:	1790504884
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK RAYMOND ALTRE

Provider Business Mailing Address
First Line	:	6200 CANOGA AVE STE 210
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91367-7794
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6200 CANOGA AVE STE 210
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91367-7794
Country	:	US
Telephone Number	:	818-805-4139
Fax Number	:

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

Provider Enumeration Date	:	10/07/2024
Last Update Date	:	10/08/2024

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