Provider Demographics
NPI:1669617163
Name:WAX, REMY FLORES (LVN)
Entity type:Individual
Prefix:MS
First Name:REMY
Middle Name:FLORES
Last Name:WAX
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:DR
Other - First Name:DAVID
Other - Middle Name:MICHAEL
Other - Last Name:WAX
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:21 FROST CT
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94521-4752
Mailing Address - Country:US
Mailing Address - Phone:925-673-5067
Mailing Address - Fax:
Practice Address - Street 1:21 FROST CT
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94521-4752
Practice Address - Country:US
Practice Address - Phone:925-673-5067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 153408103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQIC 24560Medicaid