Provider Demographics
NPI:1821551508
Name:MWAENGO, JOHN LANGALI
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:LANGALI
Last Name:MWAENGO
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 BOLINAS RD APT 75
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:CA
Mailing Address - Zip Code:94930-1948
Mailing Address - Country:US
Mailing Address - Phone:951-322-9527
Mailing Address - Fax:
Practice Address - Street 1:2280 DIAMOND BLVD STE 500
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-5719
Practice Address - Country:US
Practice Address - Phone:925-483-2223
Practice Address - Fax:925-826-5878
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41074167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF7755199OtherDRIVERS LICENSE