Healthcare Provider Details

I. General information

NPI: 1194915165
Provider Name (Legal Business Name): CARL DANIEL VACA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 05/08/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 CRENSHAW BLVD E. 100
TORRANCE CA
90503-1727
US

IV. Provider business mailing address

3424 W ORANGE AVE APT 210
ANAHEIM CA
92804-3058
US

V. Phone/Fax

Practice location:
  • Phone: 310-787-1500
  • Fax:
Mailing address:
  • Phone: 714-880-5276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: