Healthcare Provider Details

I. General information

NPI: 1588088231
Provider Name (Legal Business Name): ROBERT ZOLLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2014
Last Update Date: 02/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 N D ST
SAN BERNARDINO CA
92410-3524
US

IV. Provider business mailing address

1100 N D ST
SAN BERNARDINO CA
92410-3524
US

V. Phone/Fax

Practice location:
  • Phone: 909-884-0840
  • Fax: 909-885-6852
Mailing address:
  • Phone: 909-884-0840
  • Fax: 909-885-6852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: