Healthcare Provider Details

I. General information

NPI: 1407490824
Provider Name (Legal Business Name): RICHARD PAMPLONA TEVES RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2019
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1481 WINDSOR DR
SAN BERNARDINO CA
92404-5416
US

IV. Provider business mailing address

13803 CHAMPION WAY
EASTVALE CA
92880-9012
US

V. Phone/Fax

Practice location:
  • Phone: 909-361-6472
  • Fax: 909-203-7403
Mailing address:
  • Phone: 714-875-4922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number950285323
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95191113
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: