Healthcare Provider Details

I. General information

NPI: 1053253997
Provider Name (Legal Business Name): ANDREW MICHAEL WALLIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2026
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4065 COUNTY CIRCLE DR
RIVERSIDE CA
92503-3410
US

IV. Provider business mailing address

12698 ANDRETTI ST
MORENO VALLEY CA
92553-5203
US

V. Phone/Fax

Practice location:
  • Phone: 951-892-9873
  • Fax:
Mailing address:
  • Phone: 951-892-9873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: