Individual
JUAN LUIS CORDOVA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
1480 S IMPERIAL AVE, EL CENTRO, CA 92243-4200
(760) 455-1706
Mailing address
1480 S IMPERIAL AVE, EL CENTRO, CA 92243-4200
(760) 455-1706
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
F4704795
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
F4704795
CALIFORNIA ID
CA
Enumeration date
06/21/2018
Last updated
06/21/2018
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