Provider Demographics
NPI:1356832646
Name:GARCIA-GUEVARA, MIGUEL E (RADT1)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:E
Last Name:GARCIA-GUEVARA
Suffix:
Gender:M
Credentials:RADT1
Other - Prefix:
Other - First Name:MIGUEL
Other - Middle Name:E
Other - Last Name:GARCIA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2979 MARENGO ST APT 102
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-2082
Mailing Address - Country:US
Mailing Address - Phone:323-770-8218
Mailing Address - Fax:
Practice Address - Street 1:4920 AVALON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011-4004
Practice Address - Country:US
Practice Address - Phone:323-235-5035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty