Healthcare Provider Details

I. General information

NPI: 1073473542
Provider Name (Legal Business Name): LEONOR ISAMAR VACA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2025
Last Update Date: 11/19/2025
Certification Date: 11/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12219 ALVARO ST
LOS ANGELES CA
90059-3225
US

IV. Provider business mailing address

12219 ALVARO ST
LOS ANGELES CA
90059-3225
US

V. Phone/Fax

Practice location:
  • Phone: 323-336-5011
  • Fax:
Mailing address:
  • Phone: 323-336-5011
  • Fax: 323-336-5011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number54348
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: