Provider Demographics
NPI:1982207593
Name:FIERROS, EDGAR VALENTIN
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:VALENTIN
Last Name:FIERROS
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 STE 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:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician