Provider Demographics
NPI:1740733450
Name:VICENCIO, ERIN (LAC)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:VICENCIO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 DEEP VALLEY DR
Mailing Address - Street 2:SUITE 125 I-N
Mailing Address - City:ROLLING HILLS ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90274-3615
Mailing Address - Country:US
Mailing Address - Phone:424-304-4522
Mailing Address - Fax:
Practice Address - Street 1:655 DEEP VALLEY DR
Practice Address - Street 2:SUITE 125 I-N
Practice Address - City:ROLLING HILLS ESTATES
Practice Address - State:CA
Practice Address - Zip Code:90274-3615
Practice Address - Country:US
Practice Address - Phone:424-304-4522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-28
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC17062171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist