Healthcare Provider Details

I. General information

NPI: 1790265650
Provider Name (Legal Business Name): JUAN CORNELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2018
Last Update Date: 08/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1622 PALERMO DR
RIVERSIDE CA
92507-2393
US

IV. Provider business mailing address

1622 PALERMO DR
RIVERSIDE CA
92507-2393
US

V. Phone/Fax

Practice location:
  • Phone: 562-685-4610
  • Fax: 951-213-6898
Mailing address:
  • Phone: 562-685-4610
  • Fax: 951-213-6898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number336425651
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: