Healthcare Provider Details

I. General information

NPI: 1912629080
Provider Name (Legal Business Name): LAC T VU
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2022
Last Update Date: 01/13/2023
Certification Date: 01/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 RESERVOIR DR STE 205
SAN DIEGO CA
92120-5148
US

IV. Provider business mailing address

5555 RESERVOIR DR STE 205
SAN DIEGO CA
92120-5148
US

V. Phone/Fax

Practice location:
  • Phone: 619-286-5858
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number
License Number State

VIII. Authorized Official

Name: LAC VU
Title or Position: OWNER
Credential: MD
Phone: 619-286-5858