Healthcare Provider Details

I. General information

NPI: 1275910556
Provider Name (Legal Business Name): VINCENT HURTADO IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2015
Last Update Date: 05/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1ST LAR BAS BOX 5555642
CAMP PENDLETON CA
92054
US

IV. Provider business mailing address

1ST LAR BAS BOX 5555642
CAMP PENDLETON CA
92054
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-6212
  • Fax:
Mailing address:
  • Phone: 760-725-6212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: