Healthcare Provider Details

I. General information

NPI: 1548641269
Provider Name (Legal Business Name): MICHAEL ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2015
Last Update Date: 06/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 E FOOTHILL BLVD
RIALTO CA
92376-5230
US

IV. Provider business mailing address

9214 CITRUS AVE APT A
FONTANA CA
92335-5586
US

V. Phone/Fax

Practice location:
  • Phone: 909-876-4409
  • Fax: 909-421-9411
Mailing address:
  • Phone: 909-873-4409
  • Fax: 909-421-9411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: