Healthcare Provider Details

I. General information

NPI: 1780109819
Provider Name (Legal Business Name): VINCENT KY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2017
Last Update Date: 08/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17900 NEWHOPE ST
FOUNTAIN VALLEY CA
92708-5422
US

IV. Provider business mailing address

1909 CLUB DR
POMONA CA
91768-1270
US

V. Phone/Fax

Practice location:
  • Phone: 714-434-0344
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number33815
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: