Healthcare Provider Details

I. General information

NPI: 1386508810
Provider Name (Legal Business Name): ZACHERY R. LARUE PPS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7961 TAMARIND AVE
FONTANA CA
92336-2753
US

IV. Provider business mailing address

7961 TAMARIND AVE
FONTANA CA
92336-2753
US

V. Phone/Fax

Practice location:
  • Phone: 909-357-5680
  • Fax: 909-357-5680
Mailing address:
  • Phone: 909-357-5680
  • Fax: 909-357-5680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number220208071
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: