Basic Information
| Provider Information | |||||||||
| NPI: | 1851989206 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANGULO | ||||||||
| FirstName: | OCTAVIANO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2085 RUSTIN AVE BLDG 4 | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925072498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519558000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2085 RUSTIN AVE BLDG 4 | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925072498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519558000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2020 | ||||||||
| LastUpdateDate: | 01/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.