Provider Demographics
NPI:1073370656
Name:NELSON, REUBEN RANDALL
Entity Type:Individual
Prefix:
First Name:REUBEN
Middle Name:RANDALL
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3286 E GUASTI RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-8646
Mailing Address - Country:US
Mailing Address - Phone:909-476-2023
Mailing Address - Fax:
Practice Address - Street 1:11482 LOMA LINDA DR
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3743
Practice Address - Country:US
Practice Address - Phone:909-723-7877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA369324163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)