Provider Demographics
NPI:1174014419
Name:MAGANA BUENROSTRO, LUIS JAVIER
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:JAVIER
Last Name:MAGANA BUENROSTRO
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 1:1075 MITCHELL WAY
Mailing Address - Street 2:
Mailing Address - City:EL SOBRANTE
Mailing Address - State:CA
Mailing Address - Zip Code:94803-1024
Mailing Address - Country:US
Mailing Address - Phone:510-779-8875
Mailing Address - Fax:
Practice Address - Street 1:1075 MITCHELL WAY
Practice Address - Street 2:
Practice Address - City:EL SOBRANTE
Practice Address - State:CA
Practice Address - Zip Code:94803-1024
Practice Address - Country:US
Practice Address - Phone:510-779-8875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst