Provider Demographics
NPI:1295447340
Name:BALTAZAR, ERIKA IVETH
Entity type:Individual
Prefix:
First Name:ERIKA
Middle Name:IVETH
Last Name:BALTAZAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1344 N PAMPAS AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-3647
Mailing Address - Country:US
Mailing Address - Phone:323-749-0190
Mailing Address - Fax:
Practice Address - Street 1:1344 N PAMPAS AVE
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-3647
Practice Address - Country:US
Practice Address - Phone:909-440-7720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-20
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB8815292172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver