Healthcare Provider Details

I. General information

NPI: 1184543092
Provider Name (Legal Business Name): KENNIA CARBALLO COREAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 SPRUCE ST STE 250
RIVERSIDE CA
92507-7429
US

IV. Provider business mailing address

5388 CENTRAL AVE
RIVERSIDE CA
92504-2157
US

V. Phone/Fax

Practice location:
  • Phone: 760-634-1125
  • Fax:
Mailing address:
  • Phone: 951-286-8606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: