Healthcare Provider Details

I. General information

NPI: 1891273207
Provider Name (Legal Business Name): LUIS VACA-CORONA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2018
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23161 MILL CREEK DR STE 230
LAGUNA HILLS CA
92653-7935
US

IV. Provider business mailing address

23161 MILL CREEK DR STE 230
LAGUNA HILLS CA
92653-7935
US

V. Phone/Fax

Practice location:
  • Phone: 949-264-5350
  • Fax: 949-221-6939
Mailing address:
  • Phone: 949-264-5350
  • Fax: 949-221-6939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: