Basic Information
Provider Information | |||||||||
NPI: | 1821602160 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ALVARADO | ||||||||
FirstName: | KLARISSA | ||||||||
MiddleName: | ALICIA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RBT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2709 DEANNE ST | ||||||||
Address2: |   | ||||||||
City: | LIVE OAK | ||||||||
State: | CA | ||||||||
PostalCode: | 959532817 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5308458468 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 877 EMBARCADERO DR STE 1 | ||||||||
Address2: |   | ||||||||
City: | EL DORADO HILLS | ||||||||
State: | CA | ||||||||
PostalCode: | 957621400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9166936469 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/03/2020 | ||||||||
LastUpdateDate: | 09/03/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/03/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 374700000X |   |   | Y |   | Nursing Service Related Providers | Technician |   |
No ID Information.