Provider Demographics
NPI:1720819840
Name:BARROSO, DIEGO
Entity type:Individual
Prefix:
First Name:DIEGO
Middle Name:
Last Name:BARROSO
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 1:11982 OCOTILLO DR
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92337-0427
Mailing Address - Country:US
Mailing Address - Phone:909-997-5726
Mailing Address - Fax:
Practice Address - Street 1:11982 OCOTILLO DR
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92337-0427
Practice Address - Country:US
Practice Address - Phone:909-997-5726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-10
Last Update Date:2024-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD5546158343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)