Healthcare Provider Details

I. General information

NPI: 1053502500
Provider Name (Legal Business Name): LUISA CALACSAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 10/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 COURAGE DR
FAIRFIELD CA
94533-6717
US

IV. Provider business mailing address

3134 OLYMPIC RD
FAIRFIELD CA
94534-8326
US

V. Phone/Fax

Practice location:
  • Phone: 707-784-2140
  • Fax: 707-784-2164
Mailing address:
  • Phone: 707-373-8947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number344491
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: