Healthcare Provider Details

I. General information

NPI: 1457965097
Provider Name (Legal Business Name): BIANCA RAE FUENTES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BIANCA RAE GRUBER

II. Dates (important events)

Enumeration Date: 09/01/2020
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44065 MARGARITA RD STE 100
TEMECULA CA
92592-2741
US

IV. Provider business mailing address

2550 N HOLLYWOOD WAY STE 102
BURBANK CA
91505-5031
US

V. Phone/Fax

Practice location:
  • Phone: 866-727-8274
  • Fax:
Mailing address:
  • Phone: 866-727-8274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: