Provider Demographics
NPI:1124115456
Name:IGLESIAS, OSCAR
Entity type:Individual
Prefix:
First Name:OSCAR
Middle Name:
Last Name:IGLESIAS
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 1:9842 13TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92844-3171
Mailing Address - Country:US
Mailing Address - Phone:714-531-4624
Mailing Address - Fax:714-531-1189
Practice Address - Street 1:9842 13TH ST STE B
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92844-3171
Practice Address - Country:US
Practice Address - Phone:714-531-4624
Practice Address - Fax:714-531-1189
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1001YA0400XOtherHOUSE MANAGER