Wayne Fondren

Key facts

NPI

1164985677

Entity type

Individual (NPI type 1)

Primary specialty

Addiction (Substance Use Disorder) Counselor 101YA0400X

Practice address

18612 Santa Ana Ave
Bloomington, CA 92316-2639

Phone

(909) 421-7120

Fax

(909) 421-7128

NPI assigned

Apr 11, 2019

Sex

Male

Sole proprietor

No

Medicare participation

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD)

No

Specialties & licenses

Addresses

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Apr 11, 2019.

{
    "created_epoch": "1554940800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1554940800000",
    "number": "1164985677",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "18612 SANTA ANA AVE",
            "city": "BLOOMINGTON",
            "state": "CA",
            "postal_code": "923162639",
            "telephone_number": "909-421-7120",
            "fax_number": "909-421-7128"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "18612 SANTA ANA AVE",
            "city": "BLOOMINGTON",
            "state": "CA",
            "postal_code": "923162639",
            "telephone_number": "909-421-7120",
            "fax_number": "909-421-7128"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FONDREN",
        "first_name": "WAYNE",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2019-04-11",
        "last_updated": "2019-04-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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