Healthcare Provider Details

I. General information

NPI: 1215856604
Provider Name (Legal Business Name): ADAM VARGAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 CONCOURS STE 4102
ONTARIO CA
91764-6564
US

IV. Provider business mailing address

14547 CHOKE CHERRY DR
VICTORVILLE CA
92392-6137
US

V. Phone/Fax

Practice location:
  • Phone: 909-240-1764
  • Fax: 909-259-2369
Mailing address:
  • Phone: 442-284-9360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberY1419049
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: