Healthcare Provider Details

I. General information

NPI: 1538624051
Provider Name (Legal Business Name): HOLLISTER VU NGUYEN RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2019
Last Update Date: 11/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17732 BEACH BLVD STE G
HUNTINGTON BEACH CA
92647
US

IV. Provider business mailing address

17732 BEACH BLVD STE G
HUNTINGTON BEACH CA
92647-6881
US

V. Phone/Fax

Practice location:
  • Phone: 714-655-7142
  • Fax: 833-224-5825
Mailing address:
  • Phone: 714-655-7142
  • Fax: 833-224-5825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberD5417852
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: