Healthcare Provider Details

I. General information

NPI: 1083892517
Provider Name (Legal Business Name): MS. EVANGELINA CHAVEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 03/20/2023
Certification Date: 03/20/2023
Deactivation Date: 04/02/2020
Reactivation Date: 04/09/2020

III. Provider practice location address

525 TECHNOLOGY CT STE 105
RIVERSIDE CA
92507-2181
US

IV. Provider business mailing address

525 TECHNOLOGY CT STE 105
RIVERSIDE CA
92507-2181
US

V. Phone/Fax

Practice location:
  • Phone: 951-686-8500
  • Fax:
Mailing address:
  • Phone: 951-686-8500
  • Fax: 951-971-9754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: