Healthcare Provider Details

I. General information

NPI: 1174320816
Provider Name (Legal Business Name): MICHELINE VARGAS DRPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2025
Last Update Date: 02/28/2025
Certification Date: 02/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 CAMULOS AVE
GLENDALE CA
91208-2409
US

IV. Provider business mailing address

1630 CAMULOS AVE
GLENDALE CA
91208-2409
US

V. Phone/Fax

Practice location:
  • Phone: 818-383-4664
  • Fax:
Mailing address:
  • Phone: 818-383-4664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: