Provider Demographics
NPI:1083381396
Name:VEGA PACHECO, ANDRES
Entity Type:Individual
Prefix:
First Name:ANDRES
Middle Name:
Last Name:VEGA PACHECO
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 1:229 E PINEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60073-3417
Mailing Address - Country:US
Mailing Address - Phone:224-368-7679
Mailing Address - Fax:
Practice Address - Street 1:229 E PINEVIEW DR
Practice Address - Street 2:
Practice Address - City:ROUND LAKE PARK
Practice Address - State:IL
Practice Address - Zip Code:60073-3417
Practice Address - Country:US
Practice Address - Phone:224-368-7679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator