Provider Demographics
NPI:1770321390
Name:SALAS, EZECHIAL JOSHUA
Entity type:Individual
Prefix:
First Name:EZECHIAL
Middle Name:JOSHUA
Last Name:SALAS
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 1:1975 FURLOW DR
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-1646
Mailing Address - Country:US
Mailing Address - Phone:909-800-2422
Mailing Address - Fax:
Practice Address - Street 1:1975 FURLOW DR
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-1646
Practice Address - Country:US
Practice Address - Phone:909-800-2422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA687483164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse