Provider Demographics
NPI:1538351218
Name:REGUYAL, JOEDERICK SANTOS
Entity type:Individual
Prefix:
First Name:JOEDERICK
Middle Name:SANTOS
Last Name:REGUYAL
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 1:21000 BRYANT ST
Mailing Address - Street 2:UNIT # 6
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91304-2851
Mailing Address - Country:US
Mailing Address - Phone:818-216-6687
Mailing Address - Fax:
Practice Address - Street 1:14416 HAMLIN ST
Practice Address - Street 2:SUITE 210
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-1486
Practice Address - Country:US
Practice Address - Phone:818-989-6248
Practice Address - Fax:818-989-6214
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN206114164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse