Provider Demographics
NPI:1043987803
Name:ELIZALDE, JUAN
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:ELIZALDE
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 1:17005 GRAND MAMMOTH PL
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92394-7718
Mailing Address - Country:US
Mailing Address - Phone:213-800-3089
Mailing Address - Fax:
Practice Address - Street 1:3782 VERMONT ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92407-6948
Practice Address - Country:US
Practice Address - Phone:213-800-3089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-27
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator