Healthcare Provider Details

I. General information

NPI: 1144721051
Provider Name (Legal Business Name): MS. AMANDA MARIE CHAVEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2018
Last Update Date: 02/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50100 GOLSH RD
VALLEY CENTER CA
92082-5338
US

IV. Provider business mailing address

PO BOX 406
PAUMA VALLEY CA
92061-0406
US

V. Phone/Fax

Practice location:
  • Phone: 760-749-1410
  • Fax: 760-749-3347
Mailing address:
  • Phone: 760-749-1410
  • Fax: 760-749-3347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: