Healthcare Provider Details

I. General information

NPI: 1366696080
Provider Name (Legal Business Name): LETICIA VENEGAS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2008
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

338 S DAKOTA AVE
VANDENBERG AFB CA
93437-6307
US

IV. Provider business mailing address

338 S DAKOTA AVE
VANDENBERG AFB CA
93437-6307
US

V. Phone/Fax

Practice location:
  • Phone: 805-606-7595
  • Fax:
Mailing address:
  • Phone: 805-606-7595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number030722
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0307221
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: