MEDICARE: MR. PETER THOMAS HERNANDEZ II

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	AMFT139846	CA

General Provider Information

NPI Number	:	1740025840
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PETER THOMAS HERNANDEZ II

Provider Business Mailing Address
First Line	:	4755 BEATTY DR
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-2308
Country	:	US
Telephone Number	:	951-463-0880
Fax Number	:

Provider Business Practice Location Address
First Line	:	4755 BEATTY DR
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-2308
Country	:	US
Telephone Number	:	951-463-0880
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2024
Last Update Date	:	06/28/2024

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