1457695736 NPI number — MR. DE WAYNE D DELA GUERRA LVN

Table of content: MR. DE WAYNE D DELA GUERRA LVN (NPI 1457695736)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457695736 NPI number — MR. DE WAYNE D DELA GUERRA LVN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DELA GUERRA
Provider First Name:
DE WAYNE
Provider Middle Name:
D
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LVN
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457695736
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 74654
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90004-0654
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-793-9848
Provider Business Mailing Address Fax Number:
323-417-4865

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
928 N WESTERN AVE APT 306
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90029-3872
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-793-9848
Provider Business Practice Location Address Fax Number:
323-544-0899
Provider Enumeration Date:
11/27/2012

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: 164W00000X , with the licence number:  LPN02498 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 164X00000X , with the licence number: 240-636 , 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)