Healthcare Provider Details

I. General information

NPI: 1437308806
Provider Name (Legal Business Name): OSCAR VIVANCO JR. R.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2008
Last Update Date: 09/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39500 LIBERTY ST
FREMONT CA
94530
US

IV. Provider business mailing address

39500 LIBERTY ST
FREMONT CA
94530
US

V. Phone/Fax

Practice location:
  • Phone: 510-770-8133
  • Fax: 510-770-8140
Mailing address:
  • Phone: 510-770-8133
  • Fax: 510-770-8140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number731612
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number731612
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: