Provider Demographics
NPI:1598216798
Name:ORTIZ, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11838 CENTRAL AVE APT 49
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-1985
Mailing Address - Country:US
Mailing Address - Phone:323-884-6183
Mailing Address - Fax:
Practice Address - Street 1:11838 CENTRAL AVE APT 49
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-1985
Practice Address - Country:US
Practice Address - Phone:323-884-6183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-22
Last Update Date:2016-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility