Healthcare Provider Details

I. General information

NPI: 1396375143
Provider Name (Legal Business Name): MISS LISA NICOLE RAMOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2020
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
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: 909-873-4409
  • Fax: 909-421-4677
Mailing address:
  • Phone: 909-873-4409
  • Fax: 909-421-4677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: