Healthcare Provider Details

I. General information

NPI: 1174082671
Provider Name (Legal Business Name): NERIC REBOLLAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2019
Last Update Date: 01/24/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44460 20TH ST W SIDE B
LANCASTER CA
93534-2714
US

IV. Provider business mailing address

7226 SEPULVEDA BLVD
VAN NUYS CA
91405-2003
US

V. Phone/Fax

Practice location:
  • Phone: 714-834-1111
  • Fax:
Mailing address:
  • Phone: 818-235-1414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-53138
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: