Provider Demographics
NPI:1679379077
Name:PERDOMO, JOSE LUIS
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
Last Name:PERDOMO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24
Mailing Address - Street 2:
Mailing Address - City:HOLTVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92250-0024
Mailing Address - Country:US
Mailing Address - Phone:442-226-0503
Mailing Address - Fax:
Practice Address - Street 1:1725 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-1910
Practice Address - Country:US
Practice Address - Phone:442-226-0503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-25
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst