Active NPI
Edgar Ontiveros
- Peer Specialist
- Clearlake, CA
National Provider Identifier
1891517124
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Peer Specialist
- License
- MPSS-WEYLRB
- Practice address
- 14096 Lakeshore Dr
Clearlake, CA 95422-8160 - Phone
- (707) 994-4261
- NPI assigned
- Oct 28, 2024
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Peer Specialist | 175T00000X | MPSS-WEYLRB | CA | Primary |
Addresses
Primary practice location
14096 Lakeshore Dr
Clearlake, CA 95422-8160
Mailing address
PO Box 1024
Lucerne, CA 95458-1024
Phone (707) 274-9101
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1326252271 | Other | CA | 1326252271 |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| MPSS-WEYLRB | CA | MD | Peer Specialist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1730073600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1730246400000",
"number": "1891517124",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 1024",
"city": "LUCERNE",
"state": "CA",
"postal_code": "954581024",
"telephone_number": "707-274-9101"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "14096 LAKESHORE DR",
"city": "CLEARLAKE",
"state": "CA",
"postal_code": "954228160",
"telephone_number": "707-994-4261"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ONTIVEROS",
"first_name": "EDGAR",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2024-10-28",
"last_updated": "2024-10-30",
"certification_date": "2024-10-30",
"status": "A"
},
"taxonomies": [
{
"code": "175T00000X",
"taxonomy_group": "",
"desc": "Peer Specialist",
"state": "CA",
"license": "MPSS-WEYLRB",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "1326252271",
"identifier": "1326252271",
"state": "CA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Clearlake, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 30, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.