Healthcare Provider Details

I. General information

NPI: 1154215077
Provider Name (Legal Business Name): VLADIMR ADAN MAZA GONZALEZ N/A
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2025
Last Update Date: 06/05/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1481 WINDSOR DR
SAN BERNARDINO CA
92404-5416
US

IV. Provider business mailing address

10781 MAPLE AVE
BLOOMINGTON CA
92316-2618
US

V. Phone/Fax

Practice location:
  • Phone: 909-361-6470
  • Fax:
Mailing address:
  • Phone: 909-233-2726
  • Fax: 909-233-2726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberNA
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: