Healthcare Provider Details

I. General information

NPI: 1750277711
Provider Name (Legal Business Name): GLORIA FAJARDO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2025
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

572 N ARROWHEAD AVE
SAN BERNARDINO CA
92401-1251
US

IV. Provider business mailing address

7717 CHURCH AVE SPC 145
HIGHLAND CA
92346-4349
US

V. Phone/Fax

Practice location:
  • Phone: 951-283-5489
  • Fax:
Mailing address:
  • Phone: 840-252-7762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: