Healthcare Provider Details

I. General information

NPI: 1497576748
Provider Name (Legal Business Name): YSIDORO DANIEL ESTRADA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 10/21/2024
Certification Date: 10/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 LATHAM ST STE A
RIVERSIDE CA
92501-1735
US

IV. Provider business mailing address

4150 LATHAM ST STE A
RIVERSIDE CA
92501-1735
US

V. Phone/Fax

Practice location:
  • Phone: 951-363-0200
  • Fax:
Mailing address:
  • Phone: 951-363-0200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: