Facts
- Status
- A
- Type
- Individual
- Enumeration date
- 2025-07-24
- Last updated
- 2026-07-13
Licenses
- License CA
- 95026834
- License CA
- 95036803
- License AZ
- 332811
- License CA
- 95036803
Location
- Practice location
- 18612 SANTA ANA AVE
- City
- BLOOMINGTON CA
- Postal code
- 923162639
- Phone
- 951-990-6516
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
The OIG NPI list is not in this build yet. Confirm on OIG's search.
Nearby
Search this city from the state hub for other records in the public registry.
Removal request
Public data from NPPES and CMS. Not a credentialing determination.