Provider Demographics
NPI:1164297024
Name:GARCIA, JUAN M
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:M
Last Name:GARCIA
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 1:24301 BARK ST
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-5228
Mailing Address - Country:US
Mailing Address - Phone:949-200-2956
Mailing Address - Fax:949-297-3559
Practice Address - Street 1:24301 BARK ST
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-5228
Practice Address - Country:US
Practice Address - Phone:949-200-2956
Practice Address - Fax:949-297-3559
Is Sole Proprietor?:No
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA306005334372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion