Healthcare Provider Details

I. General information

NPI: 1134542038
Provider Name (Legal Business Name): RITA VACA MORALES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2014
Last Update Date: 01/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 GRAND AVE
LONG BEACH CA
90815-1765
US

IV. Provider business mailing address

2525 GRAND AVE
LONG BEACH CA
90815-1765
US

V. Phone/Fax

Practice location:
  • Phone: 562-570-4271
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number519051
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: