Provider Demographics
NPI:1548752413
Name:GUZMAN, SERGIO NICHOLAS JR
Entity Type:Individual
Prefix:MR
First Name:SERGIO
Middle Name:NICHOLAS
Last Name:GUZMAN
Suffix:JR
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 1:240 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BLYTHE
Mailing Address - State:CA
Mailing Address - Zip Code:92225-1609
Mailing Address - Country:US
Mailing Address - Phone:760-921-5860
Mailing Address - Fax:760-921-5886
Practice Address - Street 1:240 N BROADWAY
Practice Address - Street 2:
Practice Address - City:BLYTHE
Practice Address - State:CA
Practice Address - Zip Code:92225-1609
Practice Address - Country:US
Practice Address - Phone:760-921-5860
Practice Address - Fax:760-921-5886
Is Sole Proprietor?:No
Enumeration Date:2018-06-05
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator