Provider Demographics
NPI:1740749225
Name:VERGARA, LUIS MAURICIO
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:MAURICIO
Last Name:VERGARA
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 1:1811 E CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-3492
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1503 S COAST DR STE 212
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-1534
Practice Address - Country:US
Practice Address - Phone:657-444-9002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician