Basic Information
| Provider Information | |||||||||
| NPI: | 1922745900 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHEPPARD | ||||||||
| FirstName: | REX | ||||||||
| MiddleName: | K | ||||||||
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| Mailing Information | |||||||||
| Address1: | 33962 WAGON TRAIN DR | ||||||||
| Address2: | |||||||||
| City: | WILDOMAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925957671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519561347 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | HEMET DEPARTMENT OF BEHAVIORAL HEALTH | ||||||||
| Address2: | 650 N STATE ST | ||||||||
| City: | HEMET | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925432960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517913300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2022 | ||||||||
| LastUpdateDate: | 05/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.