Provider Demographics
NPI:1144690298
Name:AMUGO, QUEENIE
Entity type:Individual
Prefix:
First Name:QUEENIE
Middle Name:
Last Name:AMUGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 244TH ST
Mailing Address - Street 2:
Mailing Address - City:HARBOR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90710-1803
Mailing Address - Country:US
Mailing Address - Phone:310-594-6476
Mailing Address - Fax:
Practice Address - Street 1:420 E 3RD ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-1644
Practice Address - Country:US
Practice Address - Phone:213-922-8124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker