Healthcare Provider Details

I. General information

NPI: 1245007293
Provider Name (Legal Business Name): RANDY DANIEL VARGAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2023
Last Update Date: 12/11/2023
Certification Date: 12/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9431 HAVEN AVE STE 100
RANCHO CUCAMONGA CA
91730-5879
US

IV. Provider business mailing address

9431 HAVEN AVE STE 100
RANCHO CUCAMONGA CA
91730-5879
US

V. Phone/Fax

Practice location:
  • Phone: 909-780-1655
  • Fax:
Mailing address:
  • Phone: 909-780-1655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: