Healthcare Provider Details

I. General information

NPI: 1487113114
Provider Name (Legal Business Name): MRS. FAVIOLA ALFARO PANDURO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: FAVIOLA ALFARO

II. Dates (important events)

Enumeration Date: 03/12/2019
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18612 SANTA ANA AVE
BLOOMINGTON CA
92316-2639
US

IV. Provider business mailing address

290 WILSON AVE APT 206
PERRIS CA
92571-3020
US

V. Phone/Fax

Practice location:
  • Phone: 909-421-7120
  • Fax: 909-421-7128
Mailing address:
  • Phone: 951-722-7979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: