Basic Information
| Provider Information | |||||||||
| NPI: | 1588935928 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARDENAS | ||||||||
| FirstName: | SALY | ||||||||
| MiddleName: | T. | ||||||||
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| Credential: | LPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 316 E E ST | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917643712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099834466 | ||||||||
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| Practice Location | |||||||||
| Address1: | 316 E E ST | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917643712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099834466 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2012 | ||||||||
| LastUpdateDate: | 04/28/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 167G00000X | Y | Nursing Service Providers | Licensed Psychiatric Technician |
ID Information
| ID | Type | State | Issuer | Description | 1588935928 | 01 | CA | MEDI-CAL | OTHER |