Healthcare Provider Details

I. General information

NPI: 1205556362
Provider Name (Legal Business Name): JARED MILLER RADT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2022
Last Update Date: 05/13/2024
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31764 CASINO DR # 200
LAKE ELSINORE CA
92530-2312
US

IV. Provider business mailing address

5870 ARLINGTON AVE
RIVERSIDE CA
92504-2037
US

V. Phone/Fax

Practice location:
  • Phone: 951-471-4649
  • Fax: 951-471-4687
Mailing address:
  • Phone: 951-683-6596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberMPSS-QYTVPJ
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberR1476710722
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: