Healthcare Provider Details

I. General information

NPI: 1376235960
Provider Name (Legal Business Name): NICOLAS VACA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2023
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 SOMERSET CT
RAMONA CA
92065-2798
US

IV. Provider business mailing address

1333 SOMERSET CT
RAMONA CA
92065-2798
US

V. Phone/Fax

Practice location:
  • Phone: 760-300-8326
  • Fax:
Mailing address:
  • Phone: 760-300-8326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: