Provider Demographics
NPI:1326559824
Name:RUBALCAVA, OMAR
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:RUBALCAVA
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 1:18646 OXNARD ST
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-1411
Mailing Address - Country:US
Mailing Address - Phone:818-996-1051
Mailing Address - Fax:
Practice Address - Street 1:5178 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90805-6510
Practice Address - Country:US
Practice Address - Phone:818-654-3912
Practice Address - Fax:818-936-0114
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-24
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator