Provider Demographics
NPI:1083369409
Name:VASQUEZ, JORGE ALBERTO
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:ALBERTO
Last Name:VASQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6823 VARIEL AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91303-2257
Mailing Address - Country:US
Mailing Address - Phone:323-359-8468
Mailing Address - Fax:
Practice Address - Street 1:6823 VARIEL AVE APT 1
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303-2257
Practice Address - Country:US
Practice Address - Phone:323-359-8468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-14
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63402225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist