Provider Demographics
NPI:1881019123
Name:INDIVIDUAL
Entity Type:Organization
Organization Name:INDIVIDUAL
Other - Org Name:INDIVIDUAL
Other - Org Type:Other Name
Authorized Official - Title/Position:INTERN
Authorized Official - Prefix:MISS
Authorized Official - First Name:MABEL
Authorized Official - Middle Name:
Authorized Official - Last Name:VASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-428-6916
Mailing Address - Street 1:12966 EUCLID ST
Mailing Address - Street 2:SUITE 280
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-5200
Mailing Address - Country:US
Mailing Address - Phone:714-823-4770
Mailing Address - Fax:714-823-4777
Practice Address - Street 1:12966 EUCLID ST
Practice Address - Street 2:SUITE 280
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-5200
Practice Address - Country:US
Practice Address - Phone:714-823-4770
Practice Address - Fax:714-823-4777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-24
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health