Healthcare Provider Details

I. General information

NPI: 1386862068
Provider Name (Legal Business Name): GUILLERMO BEENE VICENCIO LVN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 FRENCH ST
SANTA ANA CA
92701-2475
US

IV. Provider business mailing address

1015 KENT DR
SAN DIMAS CA
91773-4611
US

V. Phone/Fax

Practice location:
  • Phone: 714-824-8140
  • Fax: 714-824-8141
Mailing address:
  • Phone: 909-962-5014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN223287
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: