Healthcare Provider Details

I. General information

NPI: 1396161923
Provider Name (Legal Business Name): MRS. SIMONE WASHINGTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2014
Last Update Date: 03/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2235 N ARROWHEAD AVE
RIALTO CA
92377-4564
US

IV. Provider business mailing address

2235 NORTH ARROWHEAD AVE.
RIALTO N/A
92377
UM

V. Phone/Fax

Practice location:
  • Phone: 909-562-4101
  • Fax:
Mailing address:
  • Phone: 909-562-4101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number366423954
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: