Basic Information
| Provider Information | |||||||||
| NPI: | 1184196867 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SNIDER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | WARREN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RADT-I | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21062 NANDINA ST | ||||||||
| Address2: | |||||||||
| City: | APPLE VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923087952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609123423 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 16248 VICTOR ST | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923953934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602437151 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2018 | ||||||||
| LastUpdateDate: | 12/19/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | R1332211218 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.