Basic Information
| Provider Information | |||||||||
| NPI: | 1003110982 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANGEL OF FAITH NON PROFIT ORGANIZATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4996 LA SIERRA AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925052612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9515002774 | ||||||||
| FaxNumber: | 9513580762 | ||||||||
| Practice Location | |||||||||
| Address1: | 4996 LA SIERRA AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925052612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9515002774 | ||||||||
| FaxNumber: | 9513580762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2011 | ||||||||
| LastUpdateDate: | 02/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | CRUZ | ||||||||
| AuthorizedOfficialFirstName: | LUIS | ||||||||
| AuthorizedOfficialMiddleName: | ALBERTO | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9515002774 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MFT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.