1255688032 NPI number — MR. JAVIER MARTIN PANAMENO CAMPOS LCSW

Table of content: CHRISTINE BALDWIN LCSWA (NPI 1053849836)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255688032 NPI number — MR. JAVIER MARTIN PANAMENO CAMPOS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PANAMENO CAMPOS
Provider First Name:
JAVIER
Provider Middle Name:
MARTIN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PANAMENO
Provider Other First Name:
JAVIER
Provider Other Middle Name:
MARTIN
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1255688032
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16025 PEACH TREE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FONTANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92337-1010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-904-0667
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
255 TERRACINA BLVD
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
REDLANDS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92373-4870
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-798-1763
Provider Business Practice Location Address Fax Number:
909-307-6405
Provider Enumeration Date:
08/10/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LCS 26127 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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