Healthcare Provider Details

I. General information

NPI: 1992277867
Provider Name (Legal Business Name): VETERANS ALCOHOLIC REHABILITATION PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2018
Last Update Date: 04/15/2024
Certification Date: 04/15/2024
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: 951-715-5040
  • Fax:
Mailing address:
  • Phone: 951-715-5040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT ANDREW JOHNSON
Title or Position: CASE MANAGER
Credential: CADC-CAS
Phone: 760-616-0602