Provider Demographics
NPI:1356012405
Name:VASQUEZ, ELISA CHAVEZ
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:CHAVEZ
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:456 S MADERA AVE
Mailing Address - Street 2:
Mailing Address - City:KERMAN
Mailing Address - State:CA
Mailing Address - Zip Code:93630-1538
Mailing Address - Country:US
Mailing Address - Phone:559-846-7115
Mailing Address - Fax:559-846-9756
Practice Address - Street 1:456 S MADERA AVE
Practice Address - Street 2:
Practice Address - City:KERMAN
Practice Address - State:CA
Practice Address - Zip Code:93630-1538
Practice Address - Country:US
Practice Address - Phone:559-846-7115
Practice Address - Fax:559-846-9756
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54249183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician