Healthcare Provider Details

I. General information

NPI: 1790520898
Provider Name (Legal Business Name): WAYLON DON KRENECK RADT-1, PSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2024
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1874 BUSINESS CENTER DR
SAN BERNARDINO CA
92408-3457
US

IV. Provider business mailing address

9626 BONITA VISTA ST
APPLE VALLEY CA
92308-9099
US

V. Phone/Fax

Practice location:
  • Phone: 909-386-0523
  • Fax:
Mailing address:
  • Phone: 760-905-7290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCI50250226
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: