Healthcare Provider Details

I. General information

NPI: 1285679233
Provider Name (Legal Business Name): VINCENT LEROY DESTIGTER RCP 9059
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

723 COURT ST
JACKSON CA
95642-2129
US

IV. Provider business mailing address

26510 SUGAR PINE DR
PIONEER CA
95666-9578
US

V. Phone/Fax

Practice location:
  • Phone: 209-223-7306
  • Fax: 209-223-7309
Mailing address:
  • Phone: 209-295-7831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227800000X
TaxonomyCertified Respiratory Therapist
License NumberRCP9059
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: