Healthcare Provider Details

I. General information

NPI: 1396669339
Provider Name (Legal Business Name): ALLEN TRISTAN ROSARIO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19150 RIVER ROCK CT
LAKE ELSINORE CA
92532-3907
US

IV. Provider business mailing address

19150 RIVER ROCK CT
LAKE ELSINORE CA
92532-3907
US

V. Phone/Fax

Practice location:
  • Phone: 562-303-7174
  • Fax:
Mailing address:
  • Phone: 562-303-7174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number729652
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: