Healthcare Provider Details

I. General information

NPI: 1013606870
Provider Name (Legal Business Name): MR. FIDENCIO FERNANDEZ CISNEROS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2023
Last Update Date: 05/05/2023
Certification Date: 05/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11206 HEATHCLIFF DR
RIVERSIDE CA
92505-2251
US

IV. Provider business mailing address

11206 HEATHCLIFF DR
RIVERSIDE CA
92505-2251
US

V. Phone/Fax

Practice location:
  • Phone: 951-741-7111
  • Fax:
Mailing address:
  • Phone: 951-741-7111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: