Healthcare Provider Details

I. General information

NPI: 1417204603
Provider Name (Legal Business Name): MARIO VEGA MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2012
Last Update Date: 07/18/2026
Certification Date: 07/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1319 VAN PELT AVE
LOS ANGELES CA
90063-1101
US

IV. Provider business mailing address

1319 VAN PELT AVE
LOS ANGELES CA
90063-1101
US

V. Phone/Fax

Practice location:
  • Phone: 323-500-9750
  • Fax:
Mailing address:
  • Phone: 323-500-9750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBCBA (1-10-6944)
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: