Provider Demographics
NPI:1841748670
Name:OLIVAREZ, MNAUEL FERNANDO
Entity type:Individual
Prefix:
First Name:MNAUEL
Middle Name:FERNANDO
Last Name:OLIVAREZ
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 1:2085 RUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-2498
Mailing Address - Country:US
Mailing Address - Phone:951-358-4100
Mailing Address - Fax:
Practice Address - Street 1:2085 RUSTIN AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2498
Practice Address - Country:US
Practice Address - Phone:951-374-3516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X103T00000X, 253J00000X
172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No253J00000XAgenciesFoster Care Agency