=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821795402
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REBECCAH RODRIGUEZ REGNER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2023
-----------------------------------------------------
Last Update Date | 08/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2305 VISTA GRANDE DR
-----------------------------------------------------
City | VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92084-2737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-421-4204
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2305 VISTA GRANDE DR
-----------------------------------------------------
City | VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92084-2737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-421-4204
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHELLE BUTLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 916-909-4910
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------