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General NPI Number Information
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NPI Number | 1083743991
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Entity Type | Individual
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Provider Name | VANESSA CEBALLOS PARK O.D.
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Gender | Female
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Dates
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Enumeration Date | 03/05/2007
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 375 E ALESSANDRO BLVD
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City | RIVERSIDE
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State | CA
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Zip | 92508-2463
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Country | US
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Telephone | 951-789-6019
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Fax | 951-789-6036
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Provider Business Mailing Address
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Address Line | 28638 QUEENSLAND DR
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City | MENIFEE
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State | CA
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Zip | 92584-7895
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Country | US
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Telephone | 951-378-8220
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 13083T
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License Number State | CA
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