Provider Demographics
NPI:1356415897
Name:CHILDRESS, SEAN JERAL
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:JERAL
Last Name:CHILDRESS
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 1:14880 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-9509
Mailing Address - Country:US
Mailing Address - Phone:909-606-3237
Mailing Address - Fax:909-606-3958
Practice Address - Street 1:14880 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-9509
Practice Address - Country:US
Practice Address - Phone:909-606-3237
Practice Address - Fax:909-606-3958
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management