Healthcare Provider Details

I. General information

NPI: 1861092876
Provider Name (Legal Business Name): JUAN ANTONIO VASQUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2020
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 S H ST
BAKERSFIELD CA
93304-5602
US

IV. Provider business mailing address

2901 S H ST
BAKERSFIELD CA
93304-5602
US

V. Phone/Fax

Practice location:
  • Phone: 661-398-4303
  • Fax: 661-326-1455
Mailing address:
  • Phone: 661-398-4303
  • Fax: 661-326-1455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1329771118
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: