Healthcare Provider Details

I. General information

NPI: 1265062855
Provider Name (Legal Business Name): ARCHIE VERADIO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2020
Last Update Date: 01/22/2020
Certification Date: 01/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2151 PROFESSIONAL DR STE 100916
ROSEVILLE CA
95661-3761
US

IV. Provider business mailing address

2151 PROFESSIONAL DR STE DR100
ROSEVILLE CA
95661-3761
US

V. Phone/Fax

Practice location:
  • Phone: 916-771-0520
  • Fax:
Mailing address:
  • Phone: 916-771-0520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: