Healthcare Provider Details

I. General information

NPI: 1376092882
Provider Name (Legal Business Name): VIRGINIA NICOLAS RESPIRATORY THERAPY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2016
Last Update Date: 09/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1902 ORANGE TREE LN STE 160
REDLANDS CA
92374-4527
US

IV. Provider business mailing address

29030 EASTON LN
HIGHLAND CA
92346-7752
US

V. Phone/Fax

Practice location:
  • Phone: 909-904-3387
  • Fax: 909-614-8080
Mailing address:
  • Phone: 909-556-7580
  • Fax: 909-614-8080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number16368
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: