Healthcare Provider Details

I. General information

NPI: 1962233650
Provider Name (Legal Business Name): ISMAIL CABARAVDIC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2024
Last Update Date: 08/13/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 E HOSPITALITY LN STE 400
SAN BERNARDINO CA
92408-3545
US

IV. Provider business mailing address

560 E HOSPITALITY LN STE 400
SAN BERNARDINO CA
92408-3545
US

V. Phone/Fax

Practice location:
  • Phone: 909-677-4000
  • Fax:
Mailing address:
  • Phone: 909-677-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: