Provider Demographics
NPI:1265463905
Name:CIFUENTES, JUAN C
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:C
Last Name:CIFUENTES
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 1:10938 VANOWEN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91605-6407
Mailing Address - Country:US
Mailing Address - Phone:818-760-2461
Mailing Address - Fax:818-760-1105
Practice Address - Street 1:10938 VANOWEN ST
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91605-6407
Practice Address - Country:US
Practice Address - Phone:818-760-2461
Practice Address - Fax:818-760-1105
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1891872594Medicaid