Healthcare Provider Details

I. General information

NPI: 1689373698
Provider Name (Legal Business Name): MARIA VACHACHIRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2023
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 PARK AVE
ORANGE PARK FL
32073-3132
US

IV. Provider business mailing address

9361 MARGAIL AVE
DES PLAINES IL
60016-4200
US

V. Phone/Fax

Practice location:
  • Phone: 904-278-7890
  • Fax:
Mailing address:
  • Phone: 224-632-0567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number21124
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: