Provider Demographics
NPI:1255420774
Name:QUINTANA, ALFRED MICHEAL (CPO)
Entity type:Individual
Prefix:MR
First Name:ALFRED
Middle Name:MICHEAL
Last Name:QUINTANA
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2365 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-3216
Mailing Address - Country:US
Mailing Address - Phone:707-445-3111
Mailing Address - Fax:707-442-8792
Practice Address - Street 1:2365 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-3216
Practice Address - Country:US
Practice Address - Phone:707-445-3111
Practice Address - Fax:707-442-8792
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGXC000320Medicaid
CAGXC000320Medicaid