Basic Information
| Provider Information | |||||||||
| NPI: | 1104458280 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALCANTARA | ||||||||
| FirstName: | KEN | ||||||||
| MiddleName: | MORALES | ||||||||
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| Credential: | BSN, RN, LVN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7246 REMMET AVE | ||||||||
| Address2: | |||||||||
| City: | CANOGA PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913031531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182060360 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8626 LOWER SACRAMENTO RD STE 41 | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952101835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094782487 | ||||||||
| FaxNumber: | 2094781476 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2020 | ||||||||
| LastUpdateDate: | 02/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 041453102 | IL | N | Nursing Service Providers | Registered Nurse | 164X00000X | 703054 | CA | Y | Nursing Service Providers | Licensed Vocational Nurse |
No ID Information.