Healthcare Provider Details

I. General information

NPI: 1982767596
Provider Name (Legal Business Name): JENNIFER L VIVANCO RPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 02/24/2020
Certification Date: 02/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11239 TAMPA AVE STE 205
PORTER RANCH CA
91326-3782
US

IV. Provider business mailing address

11239 TAMPA AVE STE 205
PORTER RANCH CA
91326-3782
US

V. Phone/Fax

Practice location:
  • Phone: 818-831-0484
  • Fax: 818-832-9389
Mailing address:
  • Phone: 818-831-0484
  • Fax: 818-832-9389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT20306
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: