Healthcare Provider Details

I. General information

NPI: 1023381886
Provider Name (Legal Business Name): TRACY LAVERIA WILBORN CERTIFICATE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2012
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1874 SO. BUSINESS CENTER DRIVE SAME AS BUSINESS MAILING ADDRESS
SAN BERNADINO CA
92408
US

IV. Provider business mailing address

1874 BUSINESS CENTER DR
SAN BERNARDINO CA
92408-3457
US

V. Phone/Fax

Practice location:
  • Phone: 909-386-0523
  • Fax: 909-386-0529
Mailing address:
  • Phone: 909-386-0523
  • Fax: 909-386-0529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: