Healthcare Provider Details

I. General information

NPI: 1831003995
Provider Name (Legal Business Name): RUDY CABACCANG CADC-I, CDVA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 GREEN RIVER RD STE 108
CORONA CA
92878-2306
US

IV. Provider business mailing address

4300 GREEN RIVER RD STE 108
CORONA CA
92878-2306
US

V. Phone/Fax

Practice location:
  • Phone: 951-409-2273
  • Fax:
Mailing address:
  • Phone: 951-409-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCI41380124
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: