Provider Demographics
NPI:1508555954
Name:BALTAZAR, JOHN KENNETH II
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:KENNETH
Last Name:BALTAZAR
Suffix:II
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 1:560 E HOSPITALITY LN STE 400
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3545
Mailing Address - Country:US
Mailing Address - Phone:909-677-4000
Mailing Address - Fax:
Practice Address - Street 1:560 E HOSPITALITY LN STE 400
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3545
Practice Address - Country:US
Practice Address - Phone:909-677-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician