Healthcare Provider Details

I. General information

NPI: 1174135958
Provider Name (Legal Business Name): MR. BRYAN DE LA FUENTE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2020
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44423 HANSTEAD AVE
LANCASTER CA
93535-3224
US

IV. Provider business mailing address

44423 HANSTEAD AVE
LANCASTER CA
93535-3224
US

V. Phone/Fax

Practice location:
  • Phone: 310-791-3064
  • Fax:
Mailing address:
  • Phone: 310-791-3064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: