1477068005 NPI number — JACOBO MACHUCA REYES BA, CADCIII

Table of content: JACOBO MACHUCA REYES BA, CADCIII (NPI 1477068005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477068005 NPI number — JACOBO MACHUCA REYES BA, CADCIII

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REYES
Provider First Name:
JACOBO
Provider Middle Name:
MACHUCA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BA, CADCIII
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:
1477068005
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3114 PATRITTI AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALDWIN PARK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91706-3503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-636-1716
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
520 N LA BREA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INGLEWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90302-3049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-933-9022
Provider Business Practice Location Address Fax Number:
323-933-4029
Provider Enumeration Date:
12/05/2017

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: 101YA0400X , with the licence number:  B00003761224 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101Y00000X , with the licence number: R1282711117 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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