Healthcare Provider Details

I. General information

NPI: 1487360541
Provider Name (Legal Business Name): JACOB ALLEN RIOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2023
Last Update Date: 01/23/2023
Certification Date: 01/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12437 LEWIS ST STE 100
GARDEN GROVE CA
92840-4651
US

IV. Provider business mailing address

5027 CORBINA WAY
OXNARD CA
93035-2814
US

V. Phone/Fax

Practice location:
  • Phone: 714-202-0118
  • Fax:
Mailing address:
  • Phone: 800-218-1563
  • 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: