Healthcare Provider Details

I. General information

NPI: 1801486709
Provider Name (Legal Business Name): REFUJIO VIVANCO JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2021
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 N STATE ST
HEMET CA
92543-2960
US

IV. Provider business mailing address

650 N STATE ST
HEMET CA
92543-2960
US

V. Phone/Fax

Practice location:
  • Phone: 951-791-3300
  • Fax:
Mailing address:
  • Phone: 951-791-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: