Healthcare Provider Details

I. General information

NPI: 1639315047
Provider Name (Legal Business Name): ANNJUDEL C ENRIQUEZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2009
Last Update Date: 01/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

769 W BLAINE ST STE B
RIVERSIDE CA
92507-3970
US

IV. Provider business mailing address

769 W BLAINE ST STE B
RIVERSIDE CA
92507-3970
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-4705
  • Fax:
Mailing address:
  • Phone: 951-358-4705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: LINDA RABER
Title or Position: SUPERVISOR
Credential:
Phone: 951-358-4705