Healthcare Provider Details

I. General information

NPI: 1457963076
Provider Name (Legal Business Name): OUTREACH NATION CLINICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2020
Last Update Date: 08/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9375 ARCHIBALD AVE STE 107
RANCHO CUCAMONGA CA
91730-5728
US

IV. Provider business mailing address

9375 ARCHIBALD AVE STE 107
RANCHO CUCAMONGA CA
91730-5728
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-8080
  • Fax: 909-360-1550
Mailing address:
  • Phone: 909-825-8080
  • Fax: 909-360-1550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MRS. KHALIDA KHANUM
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 909-825-8080