Provider Demographics
NPI:1326758160
Name:MEDINA, ANGEL IGNACIO
Entity Type:Individual
Prefix:MR
First Name:ANGEL
Middle Name:IGNACIO
Last Name:MEDINA
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 1:13371 FIRST AVE
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-8947
Mailing Address - Country:US
Mailing Address - Phone:760-261-1328
Mailing Address - Fax:
Practice Address - Street 1:6809 INDIANA AVE STE 154
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-4221
Practice Address - Country:US
Practice Address - Phone:951-774-1338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-02
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician