Healthcare Provider Details

I. General information

NPI: 1942473665
Provider Name (Legal Business Name): MR. VICTOR MANUEL RENDON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2008
Last Update Date: 10/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1633 GREMLIN WAY
SPRING VALLEY CA
91977
US

IV. Provider business mailing address

1633 GREMLINWAY
SPRING VALLEY CA
91977
US

V. Phone/Fax

Practice location:
  • Phone: 619-713-6514
  • Fax: 866-380-1013
Mailing address:
  • Phone: 619-713-6514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number5052
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: