Healthcare Provider Details

I. General information

NPI: 1861173189
Provider Name (Legal Business Name): WENCYLITO ALIVIA REGISTERED NURSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2023
Last Update Date: 07/28/2023
Certification Date: 07/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W SAN BERNARDINO RD
COVINA CA
91723-1515
US

IV. Provider business mailing address

4336 QUIROGA LN
FONTANA CA
92336-4771
US

V. Phone/Fax

Practice location:
  • Phone: 626-938-7650
  • Fax:
Mailing address:
  • Phone: 818-913-4896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number95236780
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: