Provider Demographics
NPI:1356754212
Name:CHAVEZ, CARLOS
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:CHAVEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 N AVENUE 66
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-1508
Mailing Address - Country:US
Mailing Address - Phone:626-517-2368
Mailing Address - Fax:
Practice Address - Street 1:840 N AVENUE 66
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042-1508
Practice Address - Country:US
Practice Address - Phone:626-517-2368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37203167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11241000383Medicaid