Provider Demographics
NPI:1013606870
Name:CISNEROS, FIDENCIO FERNANDEZ JR
Entity Type:Individual
Prefix:MR
First Name:FIDENCIO
Middle Name:FERNANDEZ
Last Name:CISNEROS
Suffix:JR
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 1:11206 HEATHCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-2251
Mailing Address - Country:US
Mailing Address - Phone:951-741-7111
Mailing Address - Fax:
Practice Address - Street 1:11206 HEATHCLIFF DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-2251
Practice Address - Country:US
Practice Address - Phone:951-741-7111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-05
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer