Provider Demographics
NPI:1639817638
Name:MONTENEGRO, JAVIER HERNAN
Entity Type:Individual
Prefix:
First Name:JAVIER
Middle Name:HERNAN
Last Name:MONTENEGRO
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 1:10175 BREIDT AVE
Mailing Address - Street 2:
Mailing Address - City:TUJUNGA
Mailing Address - State:CA
Mailing Address - Zip Code:91042-2564
Mailing Address - Country:US
Mailing Address - Phone:747-235-6026
Mailing Address - Fax:
Practice Address - Street 1:10175 BREIDT AVE
Practice Address - Street 2:
Practice Address - City:TUJUNGA
Practice Address - State:CA
Practice Address - Zip Code:91042-2564
Practice Address - Country:US
Practice Address - Phone:747-235-6026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-20
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23428225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist