Healthcare Provider Details

I. General information

NPI: 1245537497
Provider Name (Legal Business Name): MS. LORI JEAN DIEQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2011
Last Update Date: 10/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5870 ARLINGTON AVE #103
RIVERSIDE CA
92504-3008
US

IV. Provider business mailing address

5870 ARLINGTON AVE # 103
RIVERSIDE CA
92504-2037
US

V. Phone/Fax

Practice location:
  • Phone: 951-683-6569
  • Fax: 951-683-4239
Mailing address:
  • Phone: 951-683-6569
  • Fax: 951-683-4239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: