Healthcare Provider Details

I. General information

NPI: 1013501444
Provider Name (Legal Business Name): JOHNNIE ALDRIDGE II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2021
Last Update Date: 02/25/2021
Certification Date: 02/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2275 S MAIN ST STE 201
CORONA CA
92882-5303
US

IV. Provider business mailing address

2275 S MAIN ST STE 201
CORONA CA
92882-5303
US

V. Phone/Fax

Practice location:
  • Phone: 951-279-3222
  • Fax: 951-279-5222
Mailing address:
  • Phone: 951-279-3222
  • Fax: 951-279-5222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number97235
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: