MEDICARE: VINI EDATHARA VIJAYAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	764585	CA

General Provider Information

NPI Number	:	1952963944
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VINI EDATHARA VIJAYAN

Provider Business Mailing Address
First Line	:	5485 REPECHO DR APT L103
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92124-1710
Country	:	US
Telephone Number	:	602-476-3169
Fax Number	:

Provider Business Practice Location Address
First Line	:	5485 REPECHO DR APT L103
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92124-1710
Country	:	US
Telephone Number	:	602-476-3169
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/01/2019
Last Update Date	:	07/01/2019

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