Provider Demographics
NPI:1588791776
Name:PALOS, MIGUEL ANGEL JR
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:ANGEL
Last Name:PALOS
Suffix:JR
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 1:15229 AMAR RD
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91744-2066
Mailing Address - Country:US
Mailing Address - Phone:626-855-5090
Mailing Address - Fax:
Practice Address - Street 1:818 N SOLDANO AVE
Practice Address - Street 2:
Practice Address - City:AZUSA
Practice Address - State:CA
Practice Address - Zip Code:91702-2559
Practice Address - Country:US
Practice Address - Phone:626-334-4187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAI2001606101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)