Basic Information
Provider Information | |||||||||
NPI: | 1124603014 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GUERRERO | ||||||||
FirstName: | ISRAEL | ||||||||
MiddleName: | GEORGE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 16940 CA-14 | ||||||||
Address2: |   | ||||||||
City: | MOJAVE | ||||||||
State: | CA | ||||||||
PostalCode: | 93501 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6618245020 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4281 KATELLA AVE STE 201 | ||||||||
Address2: |   | ||||||||
City: | LOS ALAMITOS | ||||||||
State: | CA | ||||||||
PostalCode: | 907206509 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5624675440 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/12/2021 | ||||||||
LastUpdateDate: | 08/27/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/27/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X |   | CA | N |   |   |   |   | 171M00000X |   |   | Y |   | Other Service Providers | Case Manager/Care Coordinator |   | 101YM0800X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.