Healthcare Provider Details

I. General information

NPI: 1417641515
Provider Name (Legal Business Name): VANESSA M MIRANDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 06/05/2023
Certification Date: 06/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3208 ROSEMEAD BLVD 2ND FLOOR
EL MONTE CA
91731
US

IV. Provider business mailing address

3640 1/2 PERCY ST
LOS ANGELES CA
90023-1719
US

V. Phone/Fax

Practice location:
  • Phone: 626-227-7014
  • Fax:
Mailing address:
  • Phone: 323-316-7402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: