Healthcare Provider Details

I. General information

NPI: 1679901276
Provider Name (Legal Business Name): CARLOS CUERVO RAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2013
Last Update Date: 10/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2049 SKYLINE DR
LEMON GROVE CA
91945-4221
US

IV. Provider business mailing address

2049 SKYLINE DR
LEMON GROVE CA
91945-4221
US

V. Phone/Fax

Practice location:
  • Phone: 619-465-7303
  • Fax: 619-644-2503
Mailing address:
  • Phone: 619-465-7303
  • Fax: 619-644-2503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: