Provider Demographics
NPI:1407688831
Name:JOSE, CASIMIRO D JR
Entity type:Individual
Prefix:
First Name:CASIMIRO
Middle Name:D
Last Name:JOSE
Suffix:JR
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 1:2667 CHERRYBARK LN
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92881-3531
Mailing Address - Country:US
Mailing Address - Phone:951-415-0502
Mailing Address - Fax:951-432-7542
Practice Address - Street 1:2667 CHERRYBARK LN
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92881-3531
Practice Address - Country:US
Practice Address - Phone:951-415-0502
Practice Address - Fax:951-432-7542
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA336408225311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home