Healthcare Provider Details

I. General information

NPI: 1386016699
Provider Name (Legal Business Name): VICENTE BANDA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2015
Last Update Date: 04/17/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 EMELINE AVE # B-K
SANTA CRUZ CA
95060-1976
US

IV. Provider business mailing address

542 OCEAN ST STE K
SANTA CRUZ CA
95060-6622
US

V. Phone/Fax

Practice location:
  • Phone: 831-454-4170
  • Fax:
Mailing address:
  • Phone: 831-459-0444
  • Fax: 831-459-0665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: