Provider Demographics
NPI:1568117497
Name:CARTAGENA, MIGUEL JUAREZ
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:JUAREZ
Last Name:CARTAGENA
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 1:200 VENTURA PL
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-3237
Mailing Address - Country:US
Mailing Address - Phone:714-872-7032
Mailing Address - Fax:
Practice Address - Street 1:2650 N TENAYA WAY STE 180
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-1110
Practice Address - Country:US
Practice Address - Phone:702-240-2952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-18
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV225100000X
CA301622225100000X
NV4778225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist