Basic Information
| Provider Information | |||||||||
| NPI: | 1477004802 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLORES | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ACEVES | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | 09/11/2017 | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FLORES | ||||||||
| OtherFirstName: | JOHN | ||||||||
| OtherMiddleName: | ACEVES | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | R1-F1109112058 | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 656 N PARK AVE | ||||||||
| Address2: | NCADD | ||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096294084 | ||||||||
| FaxNumber: | 9096294086 | ||||||||
| Practice Location | |||||||||
| Address1: | 656 N PARK AVE | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917683679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096294084 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2016 | ||||||||
| LastUpdateDate: | 10/20/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | R1-F1109112058 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.