Provider Demographics
NPI:1417647645
Name:RENDON, IVAN ALEXANDER
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:ALEXANDER
Last Name:RENDON
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 1:139 EDGAR CT
Mailing Address - Street 2:
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91320-4332
Mailing Address - Country:US
Mailing Address - Phone:805-627-4263
Mailing Address - Fax:
Practice Address - Street 1:1500 CAMINO DEL SOL
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-3725
Practice Address - Country:US
Practice Address - Phone:805-604-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator