Provider Demographics
NPI:1033762547
Name:GUTIERREZ, JOHN CHARLES
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CHARLES
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 W 22ND ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90007-1405
Mailing Address - Country:US
Mailing Address - Phone:213-210-0062
Mailing Address - Fax:
Practice Address - Street 1:4265 S NORMANDIE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-2324
Practice Address - Country:US
Practice Address - Phone:213-210-0062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator