Healthcare Provider Details

I. General information

NPI: 1255758967
Provider Name (Legal Business Name): JUSTIN PAUL VECERE SR. IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2014
Last Update Date: 03/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

934 FRANKLIN BLVD
LEMOORE CA
93246-4600
US

IV. Provider business mailing address

937 FRANKLIN BLVD
LEMOORE CA
93246-4700
US

V. Phone/Fax

Practice location:
  • Phone: 559-998-4929
  • Fax:
Mailing address:
  • Phone: 559-998-4929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: