Provider Demographics
NPI:1386264661
Name:MEDINA, CRISTOBAL ARMANDO (RADT)
Entity type:Individual
Prefix:MR
First Name:CRISTOBAL
Middle Name:ARMANDO
Last Name:MEDINA
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:656 N PARK AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-3679
Mailing Address - Country:US
Mailing Address - Phone:909-629-4084
Mailing Address - Fax:
Practice Address - Street 1:656 N PARK AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-3679
Practice Address - Country:US
Practice Address - Phone:909-629-4084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-16
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13889-R101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)