Provider Demographics
NPI:1487271524
Name:CELEDON, FREDY (SOLE PROPRIETORSHIP)
Entity type:Individual
Prefix:
First Name:FREDY
Middle Name:
Last Name:CELEDON
Suffix:
Gender:M
Credentials:SOLE PROPRIETORSHIP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA PAULA
Mailing Address - State:CA
Mailing Address - Zip Code:93060-3238
Mailing Address - Country:US
Mailing Address - Phone:805-765-0034
Mailing Address - Fax:
Practice Address - Street 1:18111 NORDHOFF ST
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91330-0001
Practice Address - Country:US
Practice Address - Phone:818-677-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-04
Last Update Date:2020-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer