Provider Demographics
NPI:1043704034
Name:CORDOVA, JUAN LUIS
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:LUIS
Last Name:CORDOVA
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 1:1480 S IMPERIAL AVE
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-4200
Mailing Address - Country:US
Mailing Address - Phone:760-455-1706
Mailing Address - Fax:
Practice Address - Street 1:1480 S IMPERIAL AVE
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-4200
Practice Address - Country:US
Practice Address - Phone:760-455-1706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF4704795172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF4704795OtherCALIFORNIA ID