Provider Demographics
NPI:1629702402
Name:PROANO, JORGE OSWALDO
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:OSWALDO
Last Name:PROANO
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 1:8787 HALL RD
Mailing Address - Street 2:
Mailing Address - City:LAMONT
Mailing Address - State:CA
Mailing Address - Zip Code:93241
Mailing Address - Country:US
Mailing Address - Phone:661-845-5334
Mailing Address - Fax:
Practice Address - Street 1:8787 HALL RD
Practice Address - Street 2:
Practice Address - City:LAMONT
Practice Address - State:CA
Practice Address - Zip Code:93241
Practice Address - Country:US
Practice Address - Phone:661-845-5334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-15
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA171M00000X, 172V00000X
CAR1558580424101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker