Provider Demographics
NPI:1386862068
Name:VICENCIO, GUILLERMO BEENE (LVN)
Entity Type:Individual
Prefix:MR
First Name:GUILLERMO
Middle Name:BEENE
Last Name:VICENCIO
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 KENT DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-4611
Mailing Address - Country:US
Mailing Address - Phone:909-962-5014
Mailing Address - Fax:
Practice Address - Street 1:1615 FRENCH ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-2475
Practice Address - Country:US
Practice Address - Phone:714-824-8140
Practice Address - Fax:714-824-8141
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN223287164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse