Healthcare Provider Details

I. General information

NPI: 1124374715
Provider Name (Legal Business Name): RABECA VATAMANIUC CARE GIVER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2012
Last Update Date: 08/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11151 W LILY MCKINLEY DR
SURPRISE AZ
85378
US

IV. Provider business mailing address

11151 W LILY MCKINLEY DR
SURPRISE AZ
85378
US

V. Phone/Fax

Practice location:
  • Phone: 623-972-4728
  • Fax: 623-972-1467
Mailing address:
  • Phone: 623-972-4728
  • Fax: 623-972-1467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberAL8491H
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: