Provider Demographics
NPI:1942930383
Name:FLORES, EZEQUIEL REOLIN (MS)
Entity Type:Individual
Prefix:
First Name:EZEQUIEL
Middle Name:REOLIN
Last Name:FLORES
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1695 W WILLIAMS ST BANNING
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220
Mailing Address - Country:US
Mailing Address - Phone:909-485-8388
Mailing Address - Fax:
Practice Address - Street 1:21801 CACTUS AVE
Practice Address - Street 2:
Practice Address - City:MARCH ARB
Practice Address - State:CA
Practice Address - Zip Code:92518-3019
Practice Address - Country:US
Practice Address - Phone:951-233-9529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1679041495Medicaid