Healthcare Provider Details

I. General information

NPI: 1083079867
Provider Name (Legal Business Name): REYNALDO CONCEPCION
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2015
Last Update Date: 12/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HILLMONT AVENUE
VENTURA CA
93033
US

IV. Provider business mailing address

200 HILLMONT AVE.
VENTURA CA
93033
US

V. Phone/Fax

Practice location:
  • Phone: 180-565-2755
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number810578
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: