Healthcare Provider Details

I. General information

NPI: 1790197440
Provider Name (Legal Business Name): MONICA VACA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2014
Last Update Date: 11/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 TECHNOLOGY CT
RIVERSIDE CA
92507-2155
US

IV. Provider business mailing address

555 TECHNOLOGY CT
RIVERSIDE CA
92507-2155
US

V. Phone/Fax

Practice location:
  • Phone: 951-686-8500
  • Fax:
Mailing address:
  • Phone: 951-686-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: