Healthcare Provider Details

I. General information

NPI: 1861300428
Provider Name (Legal Business Name): RICARDO CHAVEZ-CORNEJO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2368 MARITIME DR STE 260
ELK GROVE CA
95758-3654
US

IV. Provider business mailing address

4661 UNDERWOOD WAY
SACRAMENTO CA
95823-1220
US

V. Phone/Fax

Practice location:
  • Phone: 916-676-0488
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: