Healthcare Provider Details

I. General information

NPI: 1265839674
Provider Name (Legal Business Name): DARRICK LE ARTIS FLYE CADC I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2014
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 E FOOTHILL BLVD
RIALTO CA
92376-5230
US

IV. Provider business mailing address

850 E FOOTHILL BLVD
RIALTO CA
92376-5230
US

V. Phone/Fax

Practice location:
  • Phone: 909-421-9425
  • Fax:
Mailing address:
  • Phone: 909-421-9425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC058730718
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: