Provider Demographics
NPI:1790109619
Name:SIEZAR, CARLOS ALBERTO JR
Entity Type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:ALBERTO
Last Name:SIEZAR
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 1:400 N. PEPPER AVE
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324
Mailing Address - Country:US
Mailing Address - Phone:909-580-3144
Mailing Address - Fax:
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:909-580-3144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-12
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health