Provider Demographics
NPI:1497176267
Name:PICO, CALEB
Entity Type:Individual
Prefix:
First Name:CALEB
Middle Name:
Last Name:PICO
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 1:12235 BEACH BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:STANTON
Mailing Address - State:CA
Mailing Address - Zip Code:90680-3939
Mailing Address - Country:US
Mailing Address - Phone:714-891-2601
Mailing Address - Fax:714-798-2266
Practice Address - Street 1:12235 BEACH BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:STANTON
Practice Address - State:CA
Practice Address - Zip Code:90680-3939
Practice Address - Country:US
Practice Address - Phone:714-891-2601
Practice Address - Fax:714-798-2266
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-22
Last Update Date:2013-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2069146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic