Healthcare Provider Details

I. General information

NPI: 1003230061
Provider Name (Legal Business Name): ANGELICA CHAVEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2014
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 W VISTA WAY
VISTA CA
92083-5704
US

IV. Provider business mailing address

524 W VISTA WAY
VISTA CA
92083-5704
US

V. Phone/Fax

Practice location:
  • Phone: 760-305-4900
  • Fax: 760-305-4919
Mailing address:
  • Phone: 760-305-4900
  • Fax: 760-305-4919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN710636
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: