Healthcare Provider Details

I. General information

NPI: 1922829670
Provider Name (Legal Business Name): MR. VINCENT FREEMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2024
Last Update Date: 01/29/2026
Certification Date: 01/29/2026
Deactivation Date: 10/25/2024
Reactivation Date: 12/04/2024

III. Provider practice location address

1963 N E ST
SAN BERNARDINO CA
92405-3919
US

IV. Provider business mailing address

1963 N E ST
SAN BERNARDINO CA
92405-3919
US

V. Phone/Fax

Practice location:
  • Phone: 909-881-6146
  • Fax: 909-881-3479
Mailing address:
  • Phone: 909-881-6146
  • Fax: 909-881-3479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1555800324
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: