=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932947397
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIO ROBERTO CUEVAS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2024
-----------------------------------------------------
Last Update Date | 07/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 333 N LANTANA ST STE 259
-----------------------------------------------------
City | CAMARILLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93010-9008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 820-426-1545
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3587 SWEETWOOD ST
-----------------------------------------------------
City | SIMI VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93063-2535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-388-7020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172V00000X
-----------------------------------------------------
Taxonomy Name | Community Health Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 373H00000X
-----------------------------------------------------
Taxonomy Name | Day Training/Habilitation Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------