Provider Demographics
NPI:1720354426
Name:HERNANDEZ, GARY R (LPT)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:R
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 IOWA AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-0520
Mailing Address - Country:US
Mailing Address - Phone:951-235-4055
Mailing Address - Fax:
Practice Address - Street 1:14677 MERRILL AV.
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335
Practice Address - Country:US
Practice Address - Phone:951-643-2350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-27
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT36206167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician