Provider Demographics
NPI:1679199137
Name:VILLA ZETINA, BERNARDO
Entity Type:Individual
Prefix:
First Name:BERNARDO
Middle Name:
Last Name:VILLA ZETINA
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 1:4146 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-3140
Mailing Address - Country:US
Mailing Address - Phone:626-353-8933
Mailing Address - Fax:
Practice Address - Street 1:4146 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-3140
Practice Address - Country:US
Practice Address - Phone:626-353-8933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-22
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician