Healthcare Provider Details

I. General information

NPI: 1851287635
Provider Name (Legal Business Name): JESUS VARGAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2025
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8133 MAGNOLIA AVE
RIVERSIDE CA
92504-3409
US

IV. Provider business mailing address

461 WINSLOW DR
CORONA CA
92879-1064
US

V. Phone/Fax

Practice location:
  • Phone: 951-688-4321
  • Fax:
Mailing address:
  • Phone: 951-751-4395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2710
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: