Healthcare Provider Details

I. General information

NPI: 1043400591
Provider Name (Legal Business Name): HENRY A. GONZALEZ RAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2007
Last Update Date: 01/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 W LA CADENA DR
RIVERSIDE CA
92501-1413
US

IV. Provider business mailing address

735 N D ST
SAN BERNARDINO CA
92401-1111
US

V. Phone/Fax

Practice location:
  • Phone: 951-784-8010
  • Fax: 951-784-2859
Mailing address:
  • Phone: 909-381-5507
  • Fax: 909-888-5938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberGO412291733
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: