Provider Demographics
NPI:1104438431
Name:FERNANDEZ, MICHAEL L
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:FERNANDEZ
Suffix:
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 1:5762 BEAVER SPRINGS CT
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-7980
Mailing Address - Country:US
Mailing Address - Phone:909-238-9383
Mailing Address - Fax:
Practice Address - Street 1:2243 N MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-1586
Practice Address - Country:US
Practice Address - Phone:909-447-5346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1184134033OtherGARCES RESIDENTIAL CARE SERVICES