Healthcare Provider Details

I. General information

NPI: 1710225172
Provider Name (Legal Business Name): ENVISION PERSONALIZED HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2013
Last Update Date: 01/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4620 ALVARADO CANYON RD SUITE 14
SAN DIEGO CA
92120-4320
US

IV. Provider business mailing address

4620 ALVARADO CANYON RD SUITE 14
SAN DIEGO CA
92120-4320
US

V. Phone/Fax

Practice location:
  • Phone: 619-229-9695
  • Fax: 619-229-9666
Mailing address:
  • Phone: 619-229-9695
  • Fax: 619-229-9666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: VANESSA L BILLEN
Title or Position: MANAGER
Credential:
Phone: 619-229-9695