Healthcare Provider Details

I. General information

NPI: 1053042358
Provider Name (Legal Business Name): HEIDI JOLIN GEBHARDT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2022
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

658 E BRIER DR STE 200
SAN BERNARDINO CA
92408-2847
US

IV. Provider business mailing address

1950 S SUNWEST LN STE 200
SAN BERNARDINO CA
92408-3248
US

V. Phone/Fax

Practice location:
  • Phone: 909-501-0700
  • Fax: 909-387-7611
Mailing address:
  • Phone: 909-252-4017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: