Healthcare Provider Details

I. General information

NPI: 1689473878
Provider Name (Legal Business Name): WELLCARE VALLEY MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2025
Last Update Date: 11/17/2025
Certification Date: 11/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10324 BALBOA BLVD STE 204
GRANADA HILLS CA
91344-7349
US

IV. Provider business mailing address

10324 BALBOA BLVD STE 225
GRANADA HILLS CA
91344-7349
US

V. Phone/Fax

Practice location:
  • Phone: 949-324-8363
  • Fax:
Mailing address:
  • Phone: 747-370-6986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: RAQUEL LACUESTA
Title or Position: CEO
Credential:
Phone: 747-370-6986