Basic Information
| Provider Information | |||||||||
| NPI: | 1841725694 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | INCLAN | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4626 NORTH GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263315316 | ||||||||
| FaxNumber: | 6263322219 | ||||||||
| Practice Location | |||||||||
| Address1: | 4626 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917242055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263315316 | ||||||||
| FaxNumber: | 6263322219 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2017 | ||||||||
| LastUpdateDate: | 04/28/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.