Healthcare Provider Details

I. General information

NPI: 1336210061
Provider Name (Legal Business Name): VANCE LAIDLAW FLETCHER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 10/16/2024
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91275 66TH AVE
MECCA CA
92254-1251
US

IV. Provider business mailing address

91275 66TH AVE
MECCA CA
92254-1251
US

V. Phone/Fax

Practice location:
  • Phone: 760-396-1249
  • Fax: 760-396-1253
Mailing address:
  • Phone: 760-396-1249
  • Fax: 760-396-1253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberC186960
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: