Healthcare Provider Details

I. General information

NPI: 1780004507
Provider Name (Legal Business Name): MADELINE VACCARE RDHAP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2014
Last Update Date: 04/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1522 S SALTAIR AVE APT 303
LOS ANGELES CA
90025-2694
US

IV. Provider business mailing address

1522 S SALTAIR AVE APT 303
LOS ANGELES CA
90025-2694
US

V. Phone/Fax

Practice location:
  • Phone: 310-283-1532
  • Fax:
Mailing address:
  • Phone: 310-283-1532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number13399
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: