Healthcare Provider Details

I. General information

NPI: 1396057683
Provider Name (Legal Business Name): MANUEL VALLE IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2010
Last Update Date: 07/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 DEL DIOS HWY APT 97
ESCONDIDO CA
92029-2250
US

IV. Provider business mailing address

910 DEL DIOS HWY APT 97
ESCONDIDO CA
92029-2250
US

V. Phone/Fax

Practice location:
  • Phone: 760-638-3720
  • Fax:
Mailing address:
  • Phone: 760-638-3720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: