Provider Demographics
NPI:1497465652
Name:CERVANTES, RAUL (LVN II)
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:
Last Name:CERVANTES
Suffix:
Gender:M
Credentials:LVN II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:678 N VERDE AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-4978
Mailing Address - Country:US
Mailing Address - Phone:626-464-0130
Mailing Address - Fax:
Practice Address - Street 1:303 E VANDERBILT WAY
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-0026
Practice Address - Country:US
Practice Address - Phone:903-987-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-29
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291623164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAJ6203Medicaid