Healthcare Provider Details

I. General information

NPI: 1285336552
Provider Name (Legal Business Name): JUAN PABLO VAZQUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

757 WESTWOOD PLZ RM 3108
LOS ANGELES CA
90095-1752
US

IV. Provider business mailing address

757 WESTWOOD PLAZA BOX 951752, 3108 RRUMC
LOS ANGELES CA
90095-1752
US

V. Phone/Fax

Practice location:
  • Phone: 310-267-9124
  • Fax: 310-267-3842
Mailing address:
  • Phone: 310-267-9132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: