Provider Demographics
NPI:1952135980
Name:CISNEROS, ADRIAN
Entity type:Individual
Prefix:
First Name:ADRIAN
Middle Name:
Last Name:CISNEROS
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 1:304 E PRUNE AVE # B
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-4508
Mailing Address - Country:US
Mailing Address - Phone:805-743-1437
Mailing Address - Fax:
Practice Address - Street 1:201 N COLLEGE DR
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-4614
Practice Address - Country:US
Practice Address - Phone:805-922-1724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-30
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26836225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist