Healthcare Provider Details

I. General information

NPI: 1164331534
Provider Name (Legal Business Name): ETHAN T VALLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6649 AMETHYST AVE UNIT 9321
RANCHO CUCAMONGA CA
91701-1557
US

IV. Provider business mailing address

423 E MERION ST
ONTARIO CA
91761-8758
US

V. Phone/Fax

Practice location:
  • Phone: 909-952-6993
  • Fax:
Mailing address:
  • Phone: 909-952-6993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: