Provider Demographics
NPI:1376700872
Name:VILLANUEVA, ERENEA DAR JUAN
Entity Type:Individual
Prefix:MRS
First Name:ERENEA
Middle Name:DAR JUAN
Last Name:VILLANUEVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3113 BIG DALTON AVE
Mailing Address - Street 2:UNIT B
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-5106
Mailing Address - Country:US
Mailing Address - Phone:626-475-2296
Mailing Address - Fax:626-962-7371
Practice Address - Street 1:3113 BIG DALTON AVE
Practice Address - Street 2:UNIT B
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-5106
Practice Address - Country:US
Practice Address - Phone:626-475-2296
Practice Address - Fax:626-962-7371
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA991572174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA991572OtherBUSINESS LICENSE