Healthcare Provider Details

I. General information

NPI: 1578483970
Provider Name (Legal Business Name): MISTER VEGA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3225 TIMBER FALL CT STE B
EUREKA CA
95503-4892
US

IV. Provider business mailing address

3225 TIMBER FALL CT STE B
EUREKA CA
95503-4892
US

V. Phone/Fax

Practice location:
  • Phone: 707-442-5700
  • Fax: 707-441-1000
Mailing address:
  • Phone: 707-442-5700
  • Fax: 707-441-1000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM1400X
TaxonomyNurse Massage Therapist (NMT)
License Number95466598
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: