Healthcare Provider Details

I. General information

NPI: 1982207593
Provider Name (Legal Business Name): EDGAR VALENTIN FIERROS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2020
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6529 RIVERSIDE AVE STE 270
RIVERSIDE CA
92506-3122
US

IV. Provider business mailing address

PO BOX 53413
IRVINE CA
92619-3413
US

V. Phone/Fax

Practice location:
  • Phone: 657-236-1287
  • Fax: 714-333-4535
Mailing address:
  • Phone: 657-236-1287
  • Fax: 714-333-4535

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: