Provider Demographics
NPI:1891945168
Name:HERNANDEZ, CARLOS
Entity Type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:
Last Name:HERNANDEZ
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 1:20 E RIENSTRA ST
Mailing Address - Street 2:#13
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-5255
Mailing Address - Country:US
Mailing Address - Phone:619-271-6233
Mailing Address - Fax:
Practice Address - Street 1:20 E RIENSTRA ST
Practice Address - Street 2:#13
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-5255
Practice Address - Country:US
Practice Address - Phone:619-271-6233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC4081219172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver