Healthcare Provider Details

I. General information

NPI: 1154882769
Provider Name (Legal Business Name): CARLOS JACOBO ADAME
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17270 ROOSEVELT ST
RIVERSIDE CA
92508-9523
US

IV. Provider business mailing address

5870 ARLINGTON AVE
RIVERSIDE CA
92504-2037
US

V. Phone/Fax

Practice location:
  • Phone: 951-683-6596
  • Fax:
Mailing address:
  • Phone: 951-683-6596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number40748
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: