Provider Demographics
NPI:1255175618
Name:SNODGRASS, ALIX
Entity type:Individual
Prefix:
First Name:ALIX
Middle Name:
Last Name:SNODGRASS
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25590 PROSPECT AVE APT 55A
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3159
Mailing Address - Country:US
Mailing Address - Phone:909-835-0151
Mailing Address - Fax:
Practice Address - Street 1:11374 MOUNTAIN VIEW AVE STE D
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3815
Practice Address - Country:US
Practice Address - Phone:909-558-6832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker