Healthcare Provider Details

I. General information

NPI: 1952129090
Provider Name (Legal Business Name): SALVADOR PEREZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2024
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10776 FREMONT ST.
YUCAIPA CA
92399
US

IV. Provider business mailing address

PO BOX 47
YUCAIPA CA
92399
US

V. Phone/Fax

Practice location:
  • Phone: 909-797-0114
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number15483
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number15483
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number15483
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: