Healthcare Provider Details

I. General information

NPI: 1982127684
Provider Name (Legal Business Name): JUAN CARLOS VENEGAS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2017
Last Update Date: 07/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17270 ROOSEVELT AVE
RIVERSIDE CA
92508
US

IV. Provider business mailing address

21651 OLD ELSINORE RD
PERRIS CA
92570
US

V. Phone/Fax

Practice location:
  • Phone: 951-780-2541
  • Fax: 951-780-5809
Mailing address:
  • Phone: 951-662-3395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: