Provider Demographics
NPI:1609435254
Name:LUCERO GONZALES, EDSON
Entity Type:Individual
Prefix:
First Name:EDSON
Middle Name:
Last Name:LUCERO GONZALES
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 1:5338 BUSHNELL AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-1317
Mailing Address - Country:US
Mailing Address - Phone:951-373-0873
Mailing Address - Fax:
Practice Address - Street 1:6800 INDIANA AVE STE 260
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-4287
Practice Address - Country:US
Practice Address - Phone:951-782-0040
Practice Address - Fax:951-782-2010
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No172V00000XOther Service ProvidersCommunity Health Worker