Healthcare Provider Details

I. General information

NPI: 1841748670
Provider Name (Legal Business Name): MNAUEL FERNANDO OLIVAREZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2016
Last Update Date: 04/21/2017
Certification Date:
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: 951-374-3516
  • Fax:
Mailing address:
  • Phone: 951-358-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number171M00000X
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number171M00000X
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: