Healthcare Provider Details

I. General information

NPI: 1982163465
Provider Name (Legal Business Name): FERNANDO BOTERO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2019
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15220 FOX RIDGE DR
FONTANA CA
92336-0230
US

IV. Provider business mailing address

15220 FOX RIDGE DR
FONTANA CA
92336-0230
US

V. Phone/Fax

Practice location:
  • Phone: 909-815-0166
  • Fax:
Mailing address:
  • Phone: 909-815-0166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number81-4404308
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number81-4404308
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: