Healthcare Provider Details

I. General information

NPI: 1134623374
Provider Name (Legal Business Name): BRANDON A VACCARO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2018
Last Update Date: 03/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1358 BLUE OAKS BLVD STE 300
ROSEVILLE CA
95678-7040
US

IV. Provider business mailing address

2721 LEDGESTONE LN
LINCOLN CA
95648-8238
US

V. Phone/Fax

Practice location:
  • Phone: 916-676-0488
  • Fax:
Mailing address:
  • Phone: 916-295-4373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: