Healthcare Provider Details

I. General information

NPI: 1912663253
Provider Name (Legal Business Name): VINICIO VIQUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: VINICIO VIQUEZ COSMETOLOGIST

II. Dates (important events)

Enumeration Date: 11/10/2021
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 23RD AVE RM 7
SEATTLE WA
98122-2919
US

IV. Provider business mailing address

1520 23RD AVE RM 7
SEATTLE WA
98122-2919
US

V. Phone/Fax

Practice location:
  • Phone: 617-694-6006
  • Fax: --
Mailing address:
  • Phone: 617-694-6006
  • Fax: --

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License NumberCL1278006
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: