Healthcare Provider Details

I. General information

NPI: 1760140149
Provider Name (Legal Business Name): VINCENT KANTALA RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2021
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10535 HOSPITAL WAY
MATHER CA
95655-4200
US

IV. Provider business mailing address

PO BOX 582243
ELK GROVE CA
95758-0038
US

V. Phone/Fax

Practice location:
  • Phone: 916-366-5406
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95257930
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: