Healthcare Provider Details

I. General information

NPI: 1295600849
Provider Name (Legal Business Name): EXAL VEGA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2025
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47825 OASIS ST
INDIO CA
92201-6950
US

IV. Provider business mailing address

1364 KATRINA LN
SAN JACINTO CA
92583-5242
US

V. Phone/Fax

Practice location:
  • Phone: 951-604-9503
  • Fax:
Mailing address:
  • Phone: 951-604-9503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-SWAGIC
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: