Provider Demographics
NPI:1508496209
Name:VARGAS, GERARDO
Entity Type:Individual
Prefix:
First Name:GERARDO
Middle Name:
Last Name:VARGAS
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:PO BOX 53413
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92619-3413
Mailing Address - Country:US
Mailing Address - Phone:657-236-1287
Mailing Address - Fax:714-333-4535
Practice Address - Street 1:6529 RIVERSIDE AVE # 270
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3122
Practice Address - Country:US
Practice Address - Phone:657-236-1287
Practice Address - Fax:714-333-4535
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician