Basic Information
| Provider Information | |||||||||
| NPI: | 1306484597 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROMAN | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | DANIEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40700 CALIFORNIA OAKS RD STE 202 | ||||||||
| Address2: | |||||||||
| City: | MURRIETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925625789 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 40700 CALIFORNIA OAKS RD STE 202 | ||||||||
| Address2: | |||||||||
| City: | MURRIETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925625789 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9518945072 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2019 | ||||||||
| LastUpdateDate: | 12/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/18/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | VN704136 | CA | Y | Nursing Service Providers | Licensed Vocational Nurse |
ID Information
| ID | Type | State | Issuer | Description | 330652655 | 05 | CA | MEDICAID |