Healthcare Provider Details

I. General information

NPI: 1013424704
Provider Name (Legal Business Name): DENISE VIZCARRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2018
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 S BRAWLEY AVE STE 2
BRAWLEY CA
92227
US

IV. Provider business mailing address

630 S BRAWLEY AVE STE 2
BRAWLEY CA
92227-3107
US

V. Phone/Fax

Practice location:
  • Phone: 760-351-0825
  • Fax: 760-344-8181
Mailing address:
  • Phone: 760-351-0825
  • Fax: 760-344-8181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: