Healthcare Provider Details

I. General information

NPI: 1114237161
Provider Name (Legal Business Name): STEPHEN PEEVY RAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2010
Last Update Date: 05/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 E HOLT AVE B
POMONA CA
91767-5406
US

IV. Provider business mailing address

113 S FIRCROFT ST
WEST COVINA CA
91791-2004
US

V. Phone/Fax

Practice location:
  • Phone: 909-620-2521
  • Fax: 909-620-9793
Mailing address:
  • Phone: 626-339-4590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberP1108261657
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: