Provider Demographics
NPI:1275910556
Name:HURTADO, VINCENT (IDC)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:HURTADO
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1ST LAR BAS
Mailing Address - Street 2:BOX 5555642
Mailing Address - City:CAMP PENDLETON
Mailing Address - State:CA
Mailing Address - Zip Code:92054
Mailing Address - Country:US
Mailing Address - Phone:760-725-6212
Mailing Address - Fax:
Practice Address - Street 1:1ST LAR BAS
Practice Address - Street 2:BOX 5555642
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92054
Practice Address - Country:US
Practice Address - Phone:760-725-6212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-06
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider