Provider Demographics
NPI:1255872008
Name:FUENTES CERVANTES, HERIBERTO
Entity type:Individual
Prefix:MR
First Name:HERIBERTO
Middle Name:
Last Name:FUENTES CERVANTES
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 1:5650 MOUNT ACKERLY DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-4016
Mailing Address - Country:US
Mailing Address - Phone:858-302-3340
Mailing Address - Fax:
Practice Address - Street 1:5650 MOUNT ACKERLY DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-4016
Practice Address - Country:US
Practice Address - Phone:858-302-3340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-13
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner