Healthcare Provider Details

I. General information

NPI: 1619534096
Provider Name (Legal Business Name): SANDRA CHAVEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2019
Last Update Date: 03/25/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4750 PALM AVE
RIVERSIDE CA
92501-4012
US

IV. Provider business mailing address

1667 E G ST APT 157
ONTARIO CA
91764-4490
US

V. Phone/Fax

Practice location:
  • Phone: 800-300-7326
  • Fax:
Mailing address:
  • Phone: 840-250-4243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number197727
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: