Healthcare Provider Details

I. General information

NPI: 1124632476
Provider Name (Legal Business Name): ELVIRA VASILCHENKO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2020
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10951 SORRENTO VALLEY RD STE 1D
SAN DIEGO CA
92121-1613
US

IV. Provider business mailing address

161 PALM AVE
IMPERIAL BEACH CA
91932-1048
US

V. Phone/Fax

Practice location:
  • Phone: 619-598-5488
  • Fax:
Mailing address:
  • Phone: 619-354-0455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number78334
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberCA18586
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: