Healthcare Provider Details

I. General information

NPI: 1588195887
Provider Name (Legal Business Name): VIVIANE LAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 03/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 STATE FARM DR
ROHNERT PARK CA
94928-2149
US

IV. Provider business mailing address

5900 STATE FARM DR
ROHNERT PARK CA
94928-2149
US

V. Phone/Fax

Practice location:
  • Phone: 707-206-3001
  • Fax: 707-206-3014
Mailing address:
  • Phone: 707-206-3001
  • Fax: 707-206-3014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number55401
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: