Healthcare Provider Details

I. General information

NPI: 1487203618
Provider Name (Legal Business Name): JUAN TINOCO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2019
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 TEXAS ST
FAIRFIELD CA
94533-6372
US

IV. Provider business mailing address

1119 E MONTE VISTA AVE
VACAVILLE CA
95688-3009
US

V. Phone/Fax

Practice location:
  • Phone: 707-469-4610
  • Fax:
Mailing address:
  • Phone: 707-469-4611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: