Healthcare Provider Details

I. General information

NPI: 1164357885
Provider Name (Legal Business Name): MR. KENNETH FILLMORE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13684 JEREMY CT
RANCHO CUCAMONGA CA
91739-2031
US

IV. Provider business mailing address

31961 LINDA LADERA ST
YUCAIPA CA
92399-1507
US

V. Phone/Fax

Practice location:
  • Phone: 909-476-2023
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: