Healthcare Provider Details

I. General information

NPI: 1255795662
Provider Name (Legal Business Name): VACCA,MORGAN,KHOSLA,LEPPLA,DEMERS,SEKHON,& BLAKE, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 08/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 WEST LINE STREET
BISHOP CA
93514-3314
US

IV. Provider business mailing address

5590 KIETZKE LN
RENO NV
89511-3019
US

V. Phone/Fax

Practice location:
  • Phone: 775-789-3986
  • Fax:
Mailing address:
  • Phone: 775-789-3986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA116313
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA91029
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberC52516
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA95206
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG87027
License Number StateCA

VIII. Authorized Official

Name: DAVID C LEPPLA
Title or Position: MANAGING PARTNER
Credential: M.D.
Phone: 775-789-3986