Facts
- Status
- A
- Type
- Individual
- Enumeration date
- 2019-01-25
- Last updated
- 2021-07-16
Licenses
- License CA
- ASW80533
- License CA
- ASW80533
Location
- Practice location
- 10776 FREMONT ST
- City
- YUCAIPA CA
- Postal code
- 923999630
- Phone
- 626-840-6194
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.