Healthcare Provider Details

I. General information

NPI: 1134052954
Provider Name (Legal Business Name): ANGEL EMMANUEL VAZQUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 GLEN COVE MARINA RD E STE 102
VALLEJO CA
94591-7237
US

IV. Provider business mailing address

150 GLEN COVE MARINA RD E STE 102
VALLEJO CA
94591-7237
US

V. Phone/Fax

Practice location:
  • Phone: 877-910-6538
  • Fax:
Mailing address:
  • Phone: 877-910-6538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberY9295344
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: