Provider Demographics
NPI:1982127684
Name:VENEGAS, JUAN CARLOS JR
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:VENEGAS
Suffix:JR
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 1:21651 OLD ELSINORE RD
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570
Mailing Address - Country:US
Mailing Address - Phone:951-662-3395
Mailing Address - Fax:
Practice Address - Street 1:17270 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92508
Practice Address - Country:US
Practice Address - Phone:951-780-2541
Practice Address - Fax:951-780-5809
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)