Healthcare Provider Details

I. General information

NPI: 1992681530
Provider Name (Legal Business Name): TINA L FLORES CADC LL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TINA LOUISE GAGNON CADC LL

II. Dates (important events)

Enumeration Date: 08/11/2025
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2085 RUSTIN AVE
RIVERSIDE CA
92507-2498
US

IV. Provider business mailing address

2085 RUSTIN AVE
RIVERSIDE CA
92507-2498
US

V. Phone/Fax

Practice location:
  • Phone: 951-955-2105
  • Fax:
Mailing address:
  • Phone: 951-955-2501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberA065680225
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberA065680225
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: