Healthcare Provider Details

I. General information

NPI: 1205050366
Provider Name (Legal Business Name): CARLOS VARGAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6355 RIVERSIDE AVE
RIVERSIDE CA
92506-3163
US

IV. Provider business mailing address

983 NOTTINGHAM DR
CORONA CA
92880-7304
US

V. Phone/Fax

Practice location:
  • Phone: 951-369-5714
  • Fax:
Mailing address:
  • Phone: 951-737-5352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: