Provider Demographics
NPI:1013775766
Name:MIRANDA, ANTONI A (CHW)
Entity Type:Individual
Prefix:
First Name:ANTONI
Middle Name:A
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31739 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-7818
Mailing Address - Country:US
Mailing Address - Phone:951-245-0506
Mailing Address - Fax:951-245-0999
Practice Address - Street 1:31739 RIVERSIDE DR STE A1
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-7818
Practice Address - Country:US
Practice Address - Phone:951-245-0505
Practice Address - Fax:951-245-0999
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker