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General NPI Number Information
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NPI Number | 1861173189
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Entity Type | Individual
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Provider Name | WENCYLITO ALIVIA REGISTERED NURSE
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Gender | Male
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Dates
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Enumeration Date | 07/28/2023
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Last Update Date | 07/28/2023
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Provider Practice Location Address
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Address Line | 210 W SAN BERNARDINO RD
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City | COVINA
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State | CA
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Zip | 91723-1515
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Country | US
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Telephone | 626-938-7650
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Fax |
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Provider Business Mailing Address
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Address Line | 4336 QUIROGA LN
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City | FONTANA
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State | CA
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Zip | 92336-4771
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Country | US
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Telephone | 818-913-4896
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WP0809X
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Taxonomy Name | Adult Psychiatric/Mental Health Registered Nurse
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License Number | 95236780
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License Number State | CA
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