Healthcare Provider Details

I. General information

NPI: 1740141613
Provider Name (Legal Business Name): ALICIA VALLEJO DEANDA CHW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4990 ARLINGTON AVE STE D
RIVERSIDE CA
92504-2757
US

IV. Provider business mailing address

4990 ARLINGTON AVE STE D
RIVERSIDE CA
92504-2757
US

V. Phone/Fax

Practice location:
  • Phone: 951-785-9011
  • Fax: 951-785-1436
Mailing address:
  • Phone: 951-785-9011
  • Fax: 951-785-1436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberA39805
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: