Provider Demographics
NPI:1639619661
Name:VARGAS, CARLOS JR.
Entity Type:Individual
Prefix:
First Name:CARLOS JR.
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 1:15645 MONICA CT
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-8739
Mailing Address - Country:US
Mailing Address - Phone:909-997-4651
Mailing Address - Fax:
Practice Address - Street 1:540 S EREMLAND DR
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-3186
Practice Address - Country:US
Practice Address - Phone:626-966-1577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-23
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9877-R101YA0400X
390200000X
CAAPCC10705101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program