Healthcare Provider Details

I. General information

NPI: 1205628849
Provider Name (Legal Business Name): BRANDON FELIX DE LA RIVA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2025
Last Update Date: 05/20/2025
Certification Date: 05/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11799 SEBASTIAN WAY STE 103
RANCHO CUCAMONGA CA
91730-0708
US

IV. Provider business mailing address

34448 YUCAIPA BLVD STE A
YUCAIPA CA
92399-2412
US

V. Phone/Fax

Practice location:
  • Phone: 760-835-7808
  • Fax:
Mailing address:
  • Phone:
  • 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: