Healthcare Provider Details

I. General information

NPI: 1962719682
Provider Name (Legal Business Name): HAIDI VATTOLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2010
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42021 E FLORIDA AVE
HEMET CA
92544-5016
US

IV. Provider business mailing address

1940 W ACACIA AVE APT# 26
HEMET CA
92545-3787
US

V. Phone/Fax

Practice location:
  • Phone: 951-925-1651
  • Fax:
Mailing address:
  • Phone: 951-929-6232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number63721
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: