Provider Demographics
NPI:1366044687
Name:GATFIELD, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:GATFIELD
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 1:23950 PRADO LN
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-9734
Mailing Address - Country:US
Mailing Address - Phone:909-514-1958
Mailing Address - Fax:
Practice Address - Street 1:5870 ARLINGTON AVENUE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-2037
Practice Address - Country:US
Practice Address - Phone:626-367-0299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-11
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA250918164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse