Provider Demographics
NPI:1508876442
Name:CARLOS VALENZUELA
Entity Type:Organization
Organization Name:CARLOS VALENZUELA
Other - Org Name:SOLE PROPRIETOR
Other - Org Type:Other Name
Authorized Official - Title/Position:CERTIFIED ORTHOTIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:VALENZUELA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-280-9174
Mailing Address - Street 1:4224 OHIO ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-1320
Mailing Address - Country:US
Mailing Address - Phone:619-280-9174
Mailing Address - Fax:619-280-9286
Practice Address - Street 1:4224 OHIO ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-1320
Practice Address - Country:US
Practice Address - Phone:619-280-9174
Practice Address - Fax:619-280-9286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGC000680Medicaid
CAGC000680Medicaid