Healthcare Provider Details

I. General information

NPI: 1639574569
Provider Name (Legal Business Name): KARINA VIZCARRA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2014
Last Update Date: 11/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1517 W GARVEY AVE N
WEST COVINA CA
91790-2138
US

IV. Provider business mailing address

13247 FOOTHILL BLVD 12202
RANCHO CUCAMONGA CA
91739-9677
US

V. Phone/Fax

Practice location:
  • Phone: 626-962-6061
  • Fax:
Mailing address:
  • Phone: 909-559-1658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number37744
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: