Provider Demographics
NPI:1306405493
Name:QUIROZ, EDGAR ISSAC
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:ISSAC
Last Name:QUIROZ
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 1:13852 BURNING TREE DR APT 26
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-4858
Mailing Address - Country:US
Mailing Address - Phone:760-881-6254
Mailing Address - Fax:
Practice Address - Street 1:9360 SANTA ANITA AVE STE 104
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-6151
Practice Address - Country:US
Practice Address - Phone:909-481-2080
Practice Address - Fax:909-277-7882
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician