Healthcare Provider Details

I. General information

NPI: 1912692849
Provider Name (Legal Business Name): JOSE MANUEL PINA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2023
Last Update Date: 01/10/2024
Certification Date: 01/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3125 MYERS ST BLDG. 2
RIVERSIDE CA
92503
US

IV. Provider business mailing address

3125 MYERS ST BLDG. 2
RIVERSIDE CA
92503
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-4840
  • Fax: 951-358-4848
Mailing address:
  • Phone: 951-358-4840
  • Fax: 951-358-4848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: