Healthcare Provider Details

I. General information

NPI: 1134644115
Provider Name (Legal Business Name): JORGE VASQUEZ CADC-I
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2017
Last Update Date: 01/27/2020
Certification Date: 01/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 W HOSPITALITY LN
SAN BERNARDINO CA
92415-3536
US

IV. Provider business mailing address

PO BOX 1221
GLENDORA CA
91740-1221
US

V. Phone/Fax

Practice location:
  • Phone: 909-421-4601
  • Fax:
Mailing address:
  • Phone: 949-478-3849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCICA01850919
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: