Provider Demographics
NPI:1912726860
Name:ASEREMO, ANNETONI VRENDAN PANIS
Entity type:Individual
Prefix:
First Name:ANNETONI VRENDAN
Middle Name:PANIS
Last Name:ASEREMO
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 1:24 CROCKETT
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-3331
Mailing Address - Country:US
Mailing Address - Phone:831-566-7991
Mailing Address - Fax:
Practice Address - Street 1:12395 LEWIS ST STE 102
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-4698
Practice Address - Country:US
Practice Address - Phone:760-664-1125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-08
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician